Dr Jean-François Maystadt, Professor of Economics at Université catholique de Louvain and Lancaster University, discusses institutional mistrust and vaccine hesitancy in Africa.
In a report published in the BMJ Global Health journal in April 2021 under the title ‘Institutional mistrust and child vaccination coverage in Africa’, researchers from the University of Antwerp, the International Food Policy Research Institute (IFPRI), Université catholique de Louvain (UCLouvain) and Lancaster University Management School investigated the potential impact of public lack of trust in institutions on rates of child vaccination uptake in regions of Africa. Dr Jean-François Maystadt, Professor of Economics at UCLouvain and Lancaster University, tells Health Europa Quarterly (HEQ) about the links between institutional mistrust and vaccine hesitancy.
What are the key risks associated with vaccine hesitancy and refusal, particularly in low- and middle-income countries?
Research has shown that immunisation is one of the most cost effective public health interventions to prevent child mortality and morbidity. The last two decades have shown progress in vaccination coverage that has translated into a global decline in the incidence of and mortality from infectious diseases. The World Health Organization (WHO) estimates that vaccination prevents two to three million deaths each year. In the last decade, however, progress in global vaccination coverage has stalled. The WHO points to vaccine hesitancy – the reluctance or refusal to vaccinate despite the availability of vaccines – as one of the causes. That is why, in 2019, it listed vaccine hesitancy among the top 10 threats to global health.
This is particularly important for Africa, as the continent is home to half of the world’s unvaccinated and under-vaccinated children. Finding ways to improve vaccination uptake may help countries to reach the Sustainable Development Goals target of reducing mortality in children aged under five to at least as low as 25 per 1,000 live births by 2030. Currently, two thirds of the 53 countries which are not on course to meet this goal are located in Africa.
In the particular context of COVID-19, this seems more relevant than ever. We know that the COVID-19 pandemic is unlikely to end until there is a global rollout of vaccines to protect against the disease. No-one is safe until everybody is safe. If people in low- and middle-income countries are not vaccinated, the pandemic is going to last longer; and the emergence of additional mutations becomes more likely. Naturally, supply and logistic constraints could partly explain why as of today (end of April 2021), only 1% of adults have received a first dose of the vaccine in Africa, in contrast with 13% globally. But what our paper shows is that even if the supply and logistic challenges would be overcome, we still need to convince people to get vaccinated.
Furthermore, the ongoing COVID-19 pandemic has caused the cancellation of supplementary measles immunisation campaigns and put the delivery of critical routine immunisation services at risk – so it is likely that vaccine hesitancy and the resulting slowdown in the vaccination coverage is further exacerbated by the COVID crisis. In a July 2020 article for the scientific journal Science, Debarati Guha-Sapir, director of the UCLouvain Centre for Research on the Epidemiology of Disasters (CRED) cautioned against the cancellation of these campaigns. This year nearly 120 million children are at risk of not being vaccinated in poor countries. According to the article, a mere 15% reduction in routine measles vaccinations could result in the deaths of nearly a quarter of a million children in poor countries.
What relationships did your study find between institutional mistrust and low rates of child vaccination?
Evidence from a small number of high-income countries, such as France and the US, showed that parents who report low trust in national authorities are less likely to vaccinate their children. Similarly, qualitative case studies in African nations such as Cameroon, the Democratic Republic of the Congo, Liberia, Nigeria, and South Sudan also suggested that mistrust toward local and national authorities could be an important contributor to vaccine hesitancy. But there was very little quantitative evidence assessing vaccine hesitancy in low- and middle-income countries, with only limited attention paid to confounding factors that may affect both vaccination uptake and public trust towards local authorities.
We were particularly interested in quantifying the role of institutional mistrust in child vaccination uptake in Africa, as the continent is home to half of the world’s unvaccinated and under-vaccinated children. We first matched information on child vaccination status for close to 167,000 children from 22 African countries with information on how much people in their subnational region trusted public authorities. We used information on 216 subnational regions, covering the time period between 2004 and 2018. We measured vaccination status by indicating whether a child had received any or all of the eight basic vaccinations recommended before the age of one; and we constructed an institutional mistrust index that combined the level of mistrust in the head of state, parliament, electoral system, courts and local government.
Vaccine hesitancy is defined as ‘as a delay in acceptance or refusal of vaccination despite availability of vaccination services’. It was therefore key in our analysis to isolate the effect of institutional mistrust from individual socioeconomic and regional characteristics that would affect the affordability and accessibility of the vaccination services. Our statistical approach therefore exploited variation in institutional mistrust over time within subnational regions and controlled for a range of potentially confounding child, parent, household and community characteristics. Intuitively, our fixed effects regression model answered the question: ‘What is the difference in child vaccination completion in a given subnational region between birth years when the level of institutional trust is low compared with another year when institutional trust is high?’.
We found that increases in mistrust in public institutions were strongly and negatively correlated with child vaccination uptake, even after controlling for differences in a number of child, caregiver, household and community characteristics, including access to and utilisation of healthcare services. Even when comparing children from households with similar socioeconomic characteristics, who live in the same area and have similar access to healthcare facilities, institutional mistrust matters significantly when it comes to parents vaccinating their children. For instance, when mistrust in local government increased by 10 percentage points, children living in that region were 11% more likely not to receive any of the eight basic vaccines (the Bacillus Calmette-Guérin (BCG) vaccine; three doses of the combined diphtheria, pertussis, and tetanus vaccine; three doses of the polio vaccine; and a dose of measles-containing vaccine) and 3.4% less likely to receive all eight of the basic vaccines.
What contributing factors affect levels of institutional mistrust? How could this be alleviated at a policy level?
Research has shown that a key dimension of vaccine hesitancy relates to trust. Various types of trust matter: for instance, a lack of trust in the vaccines themselves, mistrust in the health service sector that provides them, or mistrust in the authorities that decide on vaccination schedules and oversee the provision of health services. A lack of trust in governments may lead parents to question the vaccine information they receive from health authorities and hence affect parent’s decision to vaccinate their children. According to a recent survey conducted by Afrobarometer in West Africa, 68% of respondents reported that they mistrust the government’s information regarding the safety of COVID-19 vaccines. 60% reported they are unlikely to accept being vaccinated.
But the alleged motives of the service providers matter too. Take for instance the most famous case of vaccine hesitancy in Africa, the boycott of the polio vaccination campaign in the early 2000s in Nigeria. The boycott was based on the claim that the polio vaccine was contaminated with a fertility-reducing substance, as part of a plot by Western powers against Muslim populations. Sometimes there is the perception that the African population is used as ‘guinea pigs’ to test new drugs by profit-maximising pharmaceutical companies (even if drugs or vaccine tests are usually spread across the world).
Of course, the quality of institutions matters in the availability of vaccination services too; but our results show that even when comparing children from households with similar socio-economic characteristics, who live in the same area and have similar access to healthcare facilities, institutional mistrust matters significantly for vaccine acceptance.
An obvious implication of these findings is to strengthen ongoing communication efforts on the benefits of vaccines and to address myths and misunderstandings. However, awareness raising is unlikely to be sufficient unless trust and confidence in those providing the information and delivering vaccination services are increased. It takes a lot of effort to build trust. Building trust usually starts by recognising the parents’ concerns and then, providing reliable information from credible sources, using terms that are not confusing or too technical. To guide policy, it is important to try to identify context-specific origins of mistrust.
For instance, sometimes vaccine hesitancy has religious origins. In her recent book Stuck: how vaccine rumours start – and why they don’t go away, Professor Heidi Larson gives examples where vaccine hesitancy is not so much about vaccine safety but about the ingredients used in vaccines. She reports cases in Nigeria of Muslim populations refusing polio vaccines because of concerns about the use of porcine products in the gelatine used in the vaccines. It is then through a collaboration between the WHO and the Islamic Organization for Medical Sciences that this concern was addressed by concluding that the gelatine had gone through a process that transformed the ingredients of concern to be pure enough for use. This example shows that any policy needs to be embedded within the local context. It requires engaging with trusted political or religious leaders. One example is the so-called CORE projects which managed to address vaccine hesitancy in Northeast Nigeria by constructing trusted spaces for community dialogue and engagement in a challenging environment.
Were there any specific demographics in which levels of mistrust and/or vaccine hesitancy were particularly high?
Our quantitative analysis exploits variations in institutional mistrust over time within a given subnational region. Because there are only few subnational regions within each country, we do not have enough statistical power to conduct our analysis for a particular country or a particular sub-population. We do show that the relationship between vaccine hesitancy and institutional mistrust is not driven by a particular country or region within Africa, but rather is widespread across Sub-Saharan Africa.
That being said, the literature is full of examples where mistrust matters for vaccination acceptance, many of which are documented in Professor Larson’s Stuck. For instance, anecdotal evidence reports increased vaccine hesitancy and the role of institutional mistrust in countries like DRC, Liberia, Nigeria, or South Sudan. As mentioned before, the most famous case of vaccine hesitancy in Africa is the boycott of the polio vaccination campaign in the early 2000s in Nigeria. The boycott was based on the claim that the polio vaccine was contaminated with a fertility-reducing substance, as part of a plot by Western powers against Muslim populations. The boycott was highly politicised since it was instigated by political and religious leaders in a post-September 11 context, where there was a widespread feeling that ‘the US was at war against Muslims’.
Another example is how some communities rejected health workers and did not follow recommendations during the 2014 Ebola outbreak in West Africa. Based on a small survey in Liberia, it was shown that such resistance was not explained by the fact that people were not understanding the symptoms of Ebola or the ways in which it was transmitted. Respondents indicated instead that they could not trust the capacity and integrity of the government institutions to protect them.
Is there a need for additional or more targeted research in this field?
In absence of experimental data, identifying a causal relationship is a challenge; but the conditional associations that we document are sufficiently strong and robust to support the numerous qualitative case studies suggesting that institutional mistrust is slowing down child vaccination progress in Africa. One limit of our study is the difficulty of identifying the key roots of institutional mistrust. African economic development has been deeply rooted in the colonial past and in the history of slave trades. A better understanding of the origins of mistrust in relation to vaccine hesitancy would be needed to guide specific policies in each country.
Further research would be needed to better understand how to act on institutional mistrust and vaccine hesitancy. Lessons from successful campaigns in Africa highlight the importance of engaging with local communities, trusted political or religious leaders and providing space for open dialogue. A top-down approach is unlikely to work. However, a lot of uncertainties remain on how grassroots initiatives can be scaled up, and questions need to be asked about the role of social media within local communities. In a post-COVID-19 world where mobility is curbed and people are more isolated, we have seen social networks become ideal platforms for spreading anti-vaccination views. More research is needed to better assess some of the initiatives taken to restore trust and counteract the spread of misinformation.
Dr Jean-François Maystadt
Fonds de la Recherche Scientifique
University of Lancaster
Université catholique de Louvain