Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Can We Increase Global Rates of Vaccination?: A Critique of and Proposal for the Global Immunization Vision and Strategy Framework – Radha Sadacharan

I. Introduction

Since the first inoculation for smallpox in the 1700s in the United States, public health endeavors promoting immunization have been focused on preventing the contraction and transmission of as many diseases as possible by widespread vaccination(1). In the past twenty years alone, immunization has prevented over twenty million deaths globally from vaccine-preventable diseases (9, 10). However, we are far from the optimal situation in administering vaccines. An estimated 26.3 million infants every year remain unvaccinated for the diphtheria-tetanus-pertussis vaccine (DTP3), which is regarded as the benchmark vaccination for any child to receive (9). One in six children is not vaccinated against tuberculosis, and one in four is not vaccinated against measles (1,6,7).

Even though the prevalence vaccine-preventable diseases (VPDs) has decreased greatly, especially in developed countries, inter-country transmission causes an increased risk of VPDs, as some developing countries are not able to vaccinate their citizens with the same speed and efficiency as compared to developed countries. Because global travel has increased the rate of transmission of diseases, and immunization against VPDs has been shown to have great efficacy and cost-effectivity, various organizations and committees have met to form the Global Immunization Vision and Strategy (GIVS) program. This program seeks to fight VPDs globally through immunization over the course of ten years, from 2006 to 2015. Established as a framework for policy-makers and shareholders, GIVS has four main goals, which complement many of the Millennium Development Goals. The GIVS goals include immunizing more people against more diseases, introducing a range of newly available vaccines and technologies, integrating other critical health interventions with immunization, and managing vaccination programs within the context of global interdependence (9). Further divided into 24 strategies, the goals emphasize collaborative efforts between countries, organizations, and individuals. However, some of these strategies are unrealistic, or inapplicable to the current state of vaccination in the world.

II. Criticisms of GIVS

The current framework of GIVS does not provide an adequate strategy to address global vaccinations for three major reasons. First, the lack of flexibility within the program would not allow countries to exercise a sufficient amount of autonomy over their vaccination policies, thus impeding their ability to be responsible for their own health. Second, the lack of continuation within this strategy is an issue that will slow people from learning and retaining information regarding the benefits of vaccination, as GIVS was developed as a ten-year plan, from 2006 to 2015. Third, GIVS does not account for the irrationality of human behavior, which needs to be addressed in as controversial a topic as vaccination.

A. Lack of flexibility

GIVS seeks to on employ a standard set of vaccinations to all countries, similar to the way that vaccination programs are currently established in developed countries. Every government that has a stable vaccination plan, through some type of agency such as the Department of Health, decided the specific vaccines and a timeline of vaccination to enforce upon its citizens. These countries were given choices in strategy, and so sought to determine the best vaccination plan for their country(1,6). However, in the GIVS strategy, the standard set of vaccinations strongly recommended for every country, relies on the structure and choices of the vaccine programs of developed countries. Granted, countries targeted by GIVS are also given choices in strategy, as to how best to vaccinate their countries. Country-specific costs for immunization were taken into account in the planning of GIVS (6, 10). However, the vaccines that should be administered in each specific country have yet to be determined, and so these countries will inevitably use the default vaccination plan of the developed countries. Developing countries have exposures to different pathogens as compared to developed countries, so various VPDs are more common in some countries. For example, the prevalence of tuberculosis in Haiti and Peru far exceeds that in many other countries (4,11). In particular, multiple-drug resistant tuberculosis (MDR-TB) is a significant problem in these countries. If these countries did not have a plan of their own to target MDR-TB and were given a framework for vaccination and protection against it that was the same as the steps that the United States has taken to protect its citizens against MDR-TB, the plan would ultimately fail in Haiti and Peru. GIVS is promoting the same default plan in the form of standard set of vaccinations. GIVS must work to understand the problems, and the resources of a community, in this case a country, before creating a strategy to effect change.

The community organization theory focuses on helping groups identify a goal, mobilize resources, and develop a strategy to achieve the goal using these resources (12). In this way, the lack of flexibility in the GIVS framework for vaccination does not meet the criteria of the community organization theory, by failing to develop the strategy given the resources of the country. The lack of flexibility in the GIVS framework also poses a problem because members of communities within specific countries will not receive the full benefits of GIVS, as such a program may be recognized as predominantly a strong outside influence to change the community's way of life. Countries are not appropriately included in the identification of a vaccination goal (9). Again, GIVS fails to acknowledge the strategy supported by community organization, which seeks to involve every individual in the community in order to achieve a goal.

Not only will the inflexibility of the GIVS framework fail to involve communities in the decision-making process, it will also neglect to identify the most effective means of education of these communities. Globally, education may be approached in different ways. Some societies rely on oral learning, some on visual. Without education on the effects of vaccination, countries will not seek vaccination, and will therefore not benefit from GIVS. It seems to be the case that the GIVS strategy did not look to the community organization theory in order to ascertain the best way to implement effective vaccination programs globally.

B. Lack of continuity

GIVS relies on funding through donations, and seeks to monitor costs so that continuity in vaccinations can be established. However, donations are an exhaustive means of funding, and with the desire to research new vaccines, in addition to maintaining such staples as measles, DPT3, and tuberculosis vaccinations, these funds will run out quickly (10). The economy of many countries that fund such ventures also cannot be relied upon to be stable. While the Bill and Melinda Gates Foundation donated over 700 million dollars to the GIVS goals, donations like these cannot be expected. It gives nations a reason to believe that they have a crutch upon which to rely, in terms of paying for their own vaccinations. This aspect of the GIVS plan does not establish a solution for long-term vaccination plans, but instead will convince developing countries and governments that a solution to their VPDs will be provided, free of cost. According to the social learning theory, which highlights not just the presence of barriers and benefits as the decision-making tools people will use to help them to choose a solution to a problem, but also the effect that the community or others have on influencing a person's decision(3, 14). Although the financial aspect in the first ten years will remove the barrier of cost, this barrier will seem even greater after 2015, as people and developing countries struggle to pay for the vaccinations that were free for the last ten years. Rates of immunization are markedly lower among children from low-income families (3, 10). This result is affirmed developing countries, and socioeconomic barriers are a product of finance, lack of education, and time. Since so few members of these communities engage in immunizations, encouraging people to get vaccinated is much harder. People always want to do what others are doing. Such barriers will ultimately seem greater than the benefits people feel they may receive from being immunized.

Lack of continuity in this framework is also apparent in the time constraint of GIVS. Ten years, though it may be enough for implementation of a plan to increase vaccination rates globally, will not sustain such rates. The amount of time that it takes to win the trust, especially of residents of remote locations, would be ill-used as this program does not address ways to sustain contact with people. The social behavioral theory addresses the necessity of continuity in contact with populations in which one wishes to effect change (14). Individuals must observe others' actions, and if the presence or ability to obtain vaccines is diminished, individuals will not be able to learn such actions. GIVS must therefore be able to maintain continuity, in order for people to become accustomed to, or socialized to the idea of receiving vaccines.

C. Dependence on rationality

The primary goal of GIVS is to decrease the rates of vaccine-preventable diseases globally. However, there are people who altogether oppose vaccination. This lack of rationality is not represented in the GIVS framework, and especially concerning developing countries in which people do not have any experience regarding vaccinations, GIVS does not account for an outright refusal to be vaccinated. The GIVS seems to rely on the Health Belief Model, in which rationality is a key component.

The Health Belief Model (HBM) states that, given an action, a person may perform that action to, in this case, avoid VPDs, after an analysis of the perceived benefits and barriers to performing this action, their susceptibility to such a VPD, and the severity of the VPD (3,5). Inherent in the HBM is a person's ability to act rationally. If, then, a person realizes they are at high-risk for contracting a VPD that has an increased risk of death, and the benefits of being vaccinated far outweigh the barriers of perhaps cost and time, what is their reasoning behind not being vaccinated? Many people in developing countries are aware of the prevailing concerns that affect mortality rates in their countries, such as malaria, tetanus, and other VPDs. However, these people still do not seek out vaccinations when they are readily available. Fear is a major reason behind some groups' refusal to be vaccinated – fear that the barriers or costs of vaccination may be greater than they actually are. Their lack of information regarding vaccination, combined with the lack of a cultural cue as to how vaccination fits into their lives may be causing this fear. Since the HBM does not account for irrational reactions, like fear, to an action (1, 5), this fear must be dealt with in another way.

III. Interventions

An overarching theme that would help to provide effective changes in the GIVS framework is a breakdown of the strategy in order to be applied to each country individually. Some strategies are more relevant to certain countries than others, and this should be taken into consideration when presenting a body of government with the GIVS proposal. The use of community organization, social learning, and advertising theories will all, when used concurrently, address ways in which to increase vaccination rates globally. These three interventions are meant to be assimilated into the pre-existing GIVS structure, and in particular highlight the use of country-specific actions to increase vaccination rates.

A. Use of Community Organization Theory to promote flexibility

In order to combat the lack of flexibility in the GIVS framework, country-specific programs supported by the community organization theory can be applied. The community organization theory employs outside experts to help empower communities through identifying a problem within a community, resources that may be used to combat such a problem, and establishing a solution that the community may continue on their own (12). In terms of vaccine prevention, this theory would allow immunization experts to consult with governments of each country, to identify the country-specific VPDs that should be targeted. This would help countries to combat the most harmful VPDs within their country, and also provide residents with sound of mind in the idea that the vaccinations they are receiving are effective and necessary. The experts and government would then identify the resources that the country had, and be able to start a national vaccine program. They would still use the GIVS framework, but not have to rely on the default structure of vaccination recommended by GIVS and developing countries.

One of the current successful public health programs that focuses on community-specific solutions, headed by Partners in Health, has a specific focus on primary care in Haiti. Zanmi Lasante a group whose name means “partners in health”, was created to provide healthcare (including immunizations) to people in Haiti living with chronic diseases such as HIV and tuberculosis, who did not have adequate access to healthcare facilities (4). Zanmi Lasante was established by first sending outside experts, in the form of healthcare workers and epidemiology researchers, to speak with Haitian populations who did not have access to healthcare. After identifying the greatest issues in the population, experts worked with these areas to set up clinics which would, after a time, be self-sufficient and provide a level of care never before seen in these areas. Without the use of community organization, this program would not have been as successful. Currently, Zanmi Lasante is staffed mainly by Haitian residents, who have assumed responsibility for the health of their community, and for education the community. Another challenge that Zanmi Lasante dealt with was the corrupt and unstable government of Haiti. Many developing countries have the same problem, and the beauty of the community organization theory is that it identifies and works with the situation in order to provide the best possible solution to the identified problem, given the resources and factors such as political turmoil.

Using community organization to alter the GIVS framework in order to create a more successful vaccination program can also be supported by evidence that people are more likely to carry through with an action if they are given choices in how to approach a problem, as opposed to just one strict regulation through policy, which allows people to be more in control of their lives and therefore feel empowered by their decisions (13). This addition to GIVS, in the form of using community organization to increase flexibility and thus increase rates of vaccination globally, can be further built upon by using the social learning theory to ensure that such flexibility and empowerment remains viable.

B. Use of Social Learning Theory to promote continuity

Social learning theory explains how people acquire new forms of behavior, through observation of others' actions. This theory has the capacity to not only elicit desired actions in a population at present (vaccination in this case), but also to encourage the community to communicate what they know to others, from other children in the community, to communities surrounding them.

The lack of financial continuity can be partially solved by teaching people to become responsible for their own health. Social learning theory can be used to induce an association with receiving a vaccination, and paying for it. (This intervention, however, does rely on the success of either the first or third interventions, in which people are willing to be vaccinated because they have begun to understand the benefits of immunization.) In the context of vaccination, within the framework for each specific country, first introducing a small payment to be made when a person is vaccinated would accustom people to the idea of overcoming that small financial barrier in order to reap the benefits of vaccination. In this way, the worry of lacking finance in the overall GIVS program would at least be sullied for a longer period of time, until a more sustainable solution was found if the payments did not cover the full cost of vaccination. This payment would vary based on the country's economic status and the socioeconomic status of the people being vaccinated. Such an intervention would not only be more concentrated, it would also save money. If VPDs were avoided through vaccination, the health costs usually incurred by treating such diseases would be cut dramatically (15). Also, in the same way that buying in bulk is more cost-efficient, producing and administering many of the same immunizations to a larger group of people, rather than numerous varied vaccines to a smaller group of people would allow GIVS programs to sustain themselves financially for an extended period of time. This type of cost-efficiency would also allow more people to be vaccinated, as such immunizations would be more affordable. As more people were vaccinated, it would create a positive feedback loop – others, seeing these vaccinated people, would also seek to be vaccinated.

The social learning theory could also be applied to an effort towards ameliorating current, less challenging VPDs. There are still 52 countries in which neonatal tetanus is a significant cause of infant mortality, and so GIVS would do better to focus on significantly decreasing this number, instead of putting effort into too many fronts (8). In ten years, quite a short time span, GIVS looks to become a superhero of strategy. However, battling such a vast problem on so many small fronts will be less effective than focusing on one or two major ways to decrease VPDs globally. Some of the most effective public health policies for increasing compliance and effectiveness of interventions are not super multi-pronged attacks, but instead, focus on a few ways to address an issue with continuity, without overreaching one's ability to perform such tasks well (3, 17). Due to the idea that the social learning theory addresses the concern of lack of continuity, by encouraging linkages between stimuli in the environment and patterns of action, fewer, stronger linkages to receiving certain vaccines would be more beneficial than numerous weak linkages (14, 16, 17). If a population in sub-Saharan Africa in which measles is prevalent is aware that measles can be prevented safely, they would be more likely to seek out this solution, as opposed to learning about various vaccines that, while beneficial to their health, are not answers to problems as prevalent in their daily lives. Using the social learning theory to increase strength in linkages to promote the behavior of being vaccinated will adequately address the issue of continuity within the GIVS framework.

C. Use of Advertising Theory to address irrationality

One of the most difficult issues to address in public health intervention is the ability to actually convince people to perform a desired behavior or action. In asking people to perform an action as non-instinctual as getting vaccinated, GIVS assumes that people will be rational beings, and use science-based evidence to validate immunization. However, it cannot be assumed that people will act rationally. In order to combat irrationality, advertising theory can be used to appeal to certain cultural desires and norms, instead of relying on the HBM to explain actions.

Advertising theory seeks to entreat people to believe in a product enough to buy it, or to elicit some sort of desired action (18). In this case, it is vaccination. This theory would be able to address the irrational emotion of fear that some people possess against vaccination by promoting the benefits of vaccination. When placed in a relevant cultural context for each country, vaccination will be seen as a means of prolonging life and providing a better quality of life. Worrying about the side effects of vaccination, or of the immunizations themselves, will be secondary to the feelings of satisfaction. In effect, the advertising theory would transform fear into a feeling of empowerment, giving people the ability to make a decision regarding their healthcare choices.

Advertising theory is also beneficial in that it seeks to address specific groups (17, 18). In the United States, for example, vaccination programs are targeted at specific sub-groups, such as children, or the elderly. Vaccination programs that focus on a specific group are more successful than those that seek to promote immunizations towards everyone in a population, made up of multiple specific groups (2,3). This information can be used to utilize advertising theory by addressing one group's needs at a time, through cultural sub-groupings. For example, the prevalence of measles in sub-Saharan Africa, while it has been reduced significantly, is still disconcertingly common (19). One of the advertising ideas that could be used encourage measles vaccination of children is to create signs or radio advertisements that emphasize how much the measles, mumps, rubella vaccination (MMR) could help your child perform better in school, by causing them to miss less days of school, and by making sure they are not alienated by other children because they are diseased. The flexibility of the advertising theory in addressing a population's concerns, or cultural values, is invaluable in effecting successful public health interventions. In the scope of GIVS, advertising theory would, assuming country-specific breakdowns as mentioned previous, address much of the lack of immunization due to irrationality.

IV. Conclusion

Overall, the goals of GIVS are admirable, but to decrease the prevalence of VPDs in such a short period of time, with as many sub-goals as the GIVS framework has is near impossible. However, if the interventions proposed were put into effect, they would help to increase vaccination rates globally through focusing on country-specific issues. Such specificity will undoubtedly attract more people to the idea of increased vaccinations, especially when people in developing countries become aware of the benefits of vaccinating against country-specific prevalent VPDs such as tetanus, measles and diphtheria. Moreover, this intervention will empower countries instead of relying on a highly centralized and difficult-to-regulate global plan that essentially tells countries the best means of addressing their disease burdens without taking into account the countries' existing problems. Public health issues are population-scale concerns, but the most effective solutions to these issues identify the best ways possible to not only effect change on a large-scale, but ensure success on a small-scale. With some alterations in the ways that it addresses vaccination globally, GIVS will hopefully enter the same league of effective public health solutions.


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