Dr Susan Heydon explains how understanding people and their lives is vital for making a vaccination programme work.
Comment: Experiences from past vaccination campaigns in New Zealand and overseas tell us that an effective vaccine, supply and distribution system, and people to give the vaccine are necessary. They also tell us that without people actually getting vaccinated a programme will not be successful.
While vaccine hesitancy might seem a contemporary issue, it has a long history. A spectrum of attitudes towards vaccination has existed since it first began as a tool to help with disease control. The context has differed in each country and for each vaccination programme.
Central to implementing a successful programme are: understanding the importance of trust (whether of the science, the state or people); the many characteristics of the population at both societal and individual levels and in urban and rural areas; the background to people’s beliefs and practices; and how information is received and communicated. This knowledge is not new.
Vaccination uptake is better when a relationship of trust exists with the person giving the vaccination or promoting the message. This has become even more important as vaccines have become more controversial. They have increased in number and involve large pharmaceutical companies rather than public-sector institutes (which were often linked to health departments).
In 1965, in Nepal, a community smallpox vaccination initiative in two districts used vaccinators who were trusted locally. It achieved much higher daily vaccination rates than the official joint government/World Health Organization pilot project in the capital.
By the 1970s, previous vaccination campaigns in Britain established that patients and parents trusted a message more if they received it from their general practitioner rather than the government or other sources.
Questions about the role and boundaries of the state and distrust have continued to be important. During the Measles Mumps Rubella (MMR) crisis, British prime minister Tony Blair in late 2001 refused to confirm his young son Leo’s vaccination status. Vaccination rates dropped further.
In New Zealand, awareness of the need for tailored strategies to better reach populations has increased over time. Acknowledging differences between New Zealand’s various Pasifika communities, for example, is important because of emerging preferences by the 1990s for ethnic-specific consultation, planning and service delivery.
In 2020 the Māori Influenza Vaccination Programme increased uptake by using a whānau-centred approach, having ‘pop-up’ marae clinics and focusing on Māori workforce capability. Yet these valuable insights were slow to be introduced into New Zealand’s Covid-19 campaign contributing to ongoing lower Māori rates.
Childhood vaccination in New Zealand and overseas has now become routine, but the Covid-19 vaccination programme targets a mostly adult demographic who make their own decisions. Evidence from past campaigns has highlighted the need to adopt a ‘bottom-up’ approach, involve communities, go out to people and make it easy. Barriers need removing.
In Nepal in 1971, during the successful global smallpox eradication programme, project leaders changed the vaccination strategy to align with people’s traditional beliefs about when it was best to be vaccinated. The number of vaccinations increased despite a new limited timeframe. Also, when a case of smallpox was identified, vaccination of contacts was carried out at the same time as isolation. This helped reach hard to access groups like itinerant workers.
A rapidly escalating meningitis epidemic in 1974 in Brazil led to a government decision to vaccinate 80 percent of the population as quickly as possible. Over a period of several months in 1975, 90 million Brazilians spread over an area of 8.5 million square kilometres were vaccinated.
While allowing for a context of authoritarian politics and people’s widespread fear of the severity of the disease, the campaign approach was to vaccinate without disturbing the rhythm of people’s lives. People were vaccinated during their activities, at work or school, and vaccination sites were set up everywhere.
New Zealand has changed dramatically since vaccination against smallpox was used in the 19th Century, but the overall themes of discrimination, safety and efficacy, and moral and ethical issues which concerned people then have changed little. At any given time, these have been exacerbated or mitigated by disease visibility in the community, adverse vaccine events in New Zealand or overseas, and information/misinformation dissemination.
New Zealand’s vaccination rates have traditionally been low, and vaccination opposition has a long history. The few cases of diphtheria in the 1930s diminished people’s perceptions of the need for vaccination. The widespread presence and visible severity of polio epidemics in the 1950s increased uptake. Similar flurries in uptake occur when new towns and cities have positive Covid-19 cases.
Events such as contaminated diphtheria antitoxin in Bundaberg, Queensland in 1928, or the MMR vaccine’s link with autism in the now discredited study published in a leading medical journal in 1998, reduced uptake in either the short or longer term.
Compulsory vaccination against smallpox introduced by law into New Zealand in 1863 hurt the poor most for financial and access reasons. It became impractical to enforce and achieved little success in raising coverage. Compulsion unsurprisingly dropped out of the legislation in 1920 but has reappeared as ‘mandated’ vaccination for a large section of the population.
Throughout the Covid-19 pandemic response the need for science and politics to be aligned has been stressed, but a vaccination programme needs much more if it is to be successful. Past campaigns have already told us that understanding people, their lives and what matters to them is central to getting people vaccinated and making a programme work.
*The author declares that they have no conflict of interest.
