The ABCs of SBC

SBC in Immunisation

• UNICEF SBC • Season 1 • Episode 9

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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)

Resources (in order of mention)

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.

Qali Id:

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, ends with an N, and I promise it's not just a product of our imagination. Welcome back to the ABCs of SBC. In this episode, we'll be discussing immunization. We've come a very long way since the first vaccine. The smallpox vaccine, which was invented in 1796. This was a major breakthrough, kickstarting the development of numerous life saving vaccines and ultimately led to the global eradication of smallpox in 1980. But we still have a long way to go. Here's Catherine Russell, the executive director of UNICEF to tell us more.

Catherine Russell:

In the last 50 years, the lives of tens of millions of children have been saved largely due to one single reason, vaccines. This year marks the 50th anniversary of the essential programmeme on immunization, the way we organize and distribute vaccines all around the world. This immunization programme has helped keep children everywhere safe from many diseases, including measles, diphtheria, and polio. The immunization programme and the past 50 years have shown the world what's humanly possible when all of us, scientists, health workers, teachers, parents, and the international community come together for a common good. The triumph of vaccines has been a collective effort. And collectively we can and must protect it.

Qali Id:

Vaccines are universally recognized as among the safest, most cost effective and successful public health interventions to prevent fatalities and enhance the quality of life. So why did COVID 19 vaccines feel like such a hot, controversial topic? In this episode, we'll be speaking to three immunization specialists who've worked across the globe to ensure people are able to access and receive life saving vaccines, the challenges they've faced, and the role SBC can play in navigating those challenges. First, let's go to Francine Ganter Restrepo, a social and behaviour change specialist for immunization and health at the East and Southern Africa Regional Office at UNICEF, to understand what people's attitudes towards vaccinations are now, after a global pandemic.

Francine Ganter:

I think that there's this assumption that vaccine hesitancy is at large, particularly after COVID, we hear a lot of stories about how people have lost confidence in vaccines, but when we ask people as individuals what they want to do. We actually see the opposite. Over the last couple of years, we ran what we call a community rapid assessment. And what we found, actually, is that the vast majority of people still want to get vaccines for their children. And they believe that vaccines are important. And so that's not hesitancy because hesitancy is defined really as a motivational state, people who say they don't want to get vaccines or they're not sure they want to get vaccines. And it's usually tied in with confidence. So on both those indicators, confidence and motivation, we're actually seeing very positive results in our region. In the countries where we surveyed, always above 90 percent of people saying that they want vaccines and that they think that they're important. What we do see Instead, is this belief that other people don't want vaccines. In some countries, that was around 58 percent of people thinking that their close friends and family don't want them to get vaccines for their children.

Qali Id:

That's really interesting. So people want vaccines but are afraid their loved ones won't approve. I can already see the role social and behaviour change can play here, drawing on social sciences to understand and leverage these beliefs. But is SBC widely accepted in the immunization field? We spoke to Heidi Larson to see if she could give us some perspective. Heidi is an anthropologist and the author of stuck how vaccine rumors start and why they don't go away, which was released in 2020. She founded the Vaccine Confidence Project at the London School of Tropical Hygiene and Medicine and before that worked at UNICEF as a senior advisor on the introduction of new vaccines.

Heidi Larson:

I do think that in the last decade There has been a shift in the immunization community, but public health more broadly about the importance of understanding the social cultural context and how much that matters in people's decisions. People often refer to behavioural economics, but we shouldn't be talking about behavioural economics. We should be talking about behaviour and not just behaviour because. For instance, vaccine hesitancy is not a behaviour. Vaccine confidence is not a behaviour. It's a psychological state.

Qali Id:

Was this something that was always clear to you? The need to understand contextual and psychological factors in developing vaccine programmes?

Heidi Larson:

The turning point for me was when we faced the northern Nigeria boycott of the polio vaccine and cost the global eradication programme hundreds of millions of dollars to reset and it, you know, reinfected 20 countries previously polio free. So to me, that was it. That was a turning point where I said, this is not just a small deal. This is costing millions of dollars affecting people's lives. And the more we tried to understand what was going on, it was a lot about distrust. It was distrust about the West. It was distrust about the new government. The Northern candidate had lost to the South. It was a lot of external things. And frankly, none of them were actual adverse events. So something that happens after vaccination that's perceived to be caused by the vaccine. There wasn't even that in a lot of these cases. It was political, it was distrust, it was anxiety, so many things that I felt like we needed to look at. And frankly, in the 14 now years of the Vaccine Confidence Project, we realized how much of what we learned around vaccines is very relevant to a number of other health interventions. And that's why my current work is moving much more to the underlying issues of trust.

Qali Id:

Let's go back to Francine to hear about her experience and trust in her region.

Francine Ganter:

There's a lot of research that has been conducted over the last couple of years that shows the links between trust, trust in institutions, trust in government, and our health behaviours, our vaccine decisions in particular. So in countries where we see low trust in government, and therefore low trust in the institutions that deliver vaccine, we also see much lower uptake of vaccines. But it's not just trust in the vaccine itself. It's trust in the, you know, the entire systems that support delivery of vaccine. I think what's interesting about East and Southern Africa, or perhaps even the entire of the African continent, is the fact that the COVID 19 vaccines in particular came to, to these countries. Quite a bit later, over a year in some cases later than they did in the West and that long delay allowed for a lot of rumors to build up a lot of suspicions around the vaccine. I recall in 2022 when I was in Cameroon. and working with WHO to do some research around the behavioural and social drivers of COVID 19 vaccines. There were a lot of rumors going around about how the vaccines in the West did indeed prevent people from getting very sick. but those that had come to Cameroon were not real COVID 19 vaccines. You know, the, the rumors were around that these vaccines have been sent here to make the African population infertile or to exterminate the African population. And so of course, a lot of those rumors are tied in with the colonial histories in these countries. And, you know, rightfully so a lack of trust in Western institutions and a lack of trust in leadership that is seen to be, you know, working together with Western institutions to the detriment of African people. So that was quite challenging. But what we noted in Cameroon, when we started inserted efforts around COVID 19 vaccination campaigns was that if people were being offered the vaccine In a convenient way, and by people who they trusted, they would actually accept a COVID 19 vaccine, despite all the rumors that they'd heard. As part of the research I was doing in Cameroon, we learned that the COVID 19 vaccines had been made available in major hospitals in the cities, but they were not available, let's say, at the local health facilities where people had, let's say, the midwife that they trusted that delivered their child, right? Or the local doctors that they went to when they had a problem. People said that they didn't know those doctors and didn't trust those doctors in the big hospitals. And at the same time, some of their local clinics were equally suspicious of COVID 19 vaccines. So it became very clear for us that we needed to work much more closely with the smaller clinics in the peripheries and not just the big hospitals and really make sure that the health workers in those areas were well equipped to talk about COVID 19 vaccination with people who were coming in and had questions about that. And particularly, we needed to facilitate access to the vaccine because they were not willing to spend time or money on transport. to travel into the city center, you know, from wherever they were living in the suburbs or rural areas outside to go get a vaccine that they were not yet convinced that they needed, that was actually going to be beneficial to their health. And we saw the same in many countries across Africa.

Qali Id:

Histories of colonialism, mistrust in governments and institutions delivering the vaccine. It makes sense why misinformation can really take hold in these environments. To understand misinformation a bit more, let's go to Dr. Saad Omer. An epidemiologist and the founding dean of the Peter O'Donnell, Jr. School of Public Health at UT Southwestern Medical Center in Dallas, Texas, and previously headed the Yale Institute for Global Health.

Dr. Saad Omer:

So, in terms of misinformation and disinformation. Misinformation is information that is not correct. In our case, health related information, but it could be intentional or unintentional. Misinformation traditionally is unintentional, incorrect information. Disinformation, by definition, is someone intentionally spreading a piece of information that happens to be incorrect, but the intent part differentiates it from misinformation. Sometimes we use misinformation as an overarching term, and sometimes, you know, it starts as disinformation, but the second order spread is misinformation, in the sense that the person who received the piece of disinformation, when they pass on, they don't know themselves whether it's, uh, that it was intentionally spread. I wrote an op ed on the New York Times, and I think it came out on January 23rd, 2020. With one confirmed case of COVID 19 in the United States, it had just barely started spreading. And so I warned of misinformation being part of what we should expect to see. So That wasn't surprising because it was not my first rodeo, not my first outbreak, not my first pandemic. And there were serious people, serious well-meaning journalists, communications people, who just assumed that when the vaccine will come, people will roll up their sleeves and go get vaccinated. Again, those of us who had been part of these responses knew that that was wishful thinking.

Qali Id:

In a climate of misinformation, it's understandable that people would not be lining up to get vaccinated. But even before COVID and the misinformation, were people accepting of vaccines?

Heidi Larson:

Pre COVID there was already plateauing for really a decade and in some countries dropping of vaccine acceptance. I think some of it's access, but also there's been quite a significant transition in the vaccine landscape. There's a lot more vaccines out there. I think that we Kept adding more and more vaccines without a proportionate amount of engagement, communication, support around them. I mean, there was a huge investment around EPI, the expanded programme of immunization, in the beginning, in the engagement, in the communication, in the trust building, to get those six basic vaccines from 20 percent to 80 percent globally. It was tremendous.

Qali Id:

Why do you think that there's been less investment in engagement, communication, and trust building?

Heidi Larson:

It's a much more complex vaccine environment. They're more expensive and have different kind of storage and so I think countries have been struggling with this or they'll start one of the new vaccines and then can't keep it up. You know, we've kind of taken the public's trust for granted on vaccines. Frankly, I think far too long.

Qali Id:

So far we've touched on a number of factors that might cause a person to not get vaccinated. You think your family members might disapprove. You might not trust the governments delivering the vaccine. What we've yet to touch on. is when your health system isn't adequately funded. Let's go back to Francine.

Francine Ganter:

In some countries, we see the issue is that people are being charged for vaccination services that should be free. Even though vaccines are subsidized by the government and the mother should be able to come in or a father should be able to come in and get their child vaccinated free of cost, sometimes health workers will charge a fee for that. And it's often been because health workers haven't been paid. And so they're trying to top 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 often talking about, one vaccinator, one doctor, one nurse, one midwife who's attending to a whole cohort of people, an entire set of villages. And that's really tricky to manage when you're the only person in and you, you don't have help. It often means that we see outreach cancelled as well, so where health workers should be going out into the villages to deliver vaccines to people who are unable to come in. where they're understaffed, they tend not to do that. And so again, that results in missed opportunities for, for vaccination. Some of the other service experience elements that we've seen that tend to result in people not getting vaccinated is the service that you get once you're there, the treatment you get from health workers. Again, These are people, you know, they have good intentions, but they're understaffed, they're under resourced and overwhelmed, so sometimes perhaps not as patient or respectful as they could be with clients who come in, and this results in a lot of frustration for people perhaps who've traveled a long way to bring their child in for vaccination, and they're, you know, berated because they forgot their vaccination card. Or they're told that they came in late, and they're told off about that. So they get frustrated, and they might not come back. And that's really important with routine immunization, because it's not a one off thing, right? A parent will have to come in many times over to see their child fully vaccinated. So it's really important that we create positive service experiences.

Qali Id:

What other elements of the service experience have you come across in your work that can really impact a person's decision to get vaccinated?

Francine Ganter:

There's a number of, you know, service experience issues that, you know, are leading up to the point of vaccination that happen at the point of vaccination. And then also, after the fact, after the service. So, for example, we often see that parents don't know when to come back for vaccines. It may be written on the vaccination card, but when you're dealing with populations that have low literacy levels. Or they might not speak the kind of official language of the country, but they'll speak some of the tribal languages, it's a challenge to communicate those things, and so that doesn't always happen in the way that we'd ideally like to see it. And that results in parents not coming back, or not coming back on time. for the next vaccine as well.

Qali Id:

So making sure clinics are well staffed and that vaccination cards are easy to understand will help ensure more people get vaccinated and come back for more. Let's go back to Saad who can explain why these actions are key to rebuilding trust.

Dr. Saad Omer:

Competence in public health response is not talked about enough as an antidote to mistrust in institutions. We trust institutions We trust, let's say, a courier, you know, FedEx or DHL, that picks up a package from Accra, Ghana, and gets it to Addis Ababa, or Dhaka, or Karachi, or Kathmandu, or Kansas, because it delivers. Delivers for this case literally delivers for us for international organizations, for local governments, for public health agencies to rebuild trust is to deliver for the people and the trust will come, get the vaccines to where people need them, provide services, quality of services in peripheral primary head healthcare locations, making sure that bed nets are there, that antenatal care is there. Making sure that when people come to healthcare facilities, they're treated with respect and dignity. These kinds of things build a healthy connection between those who are mandated to serve the public and the public who is supposed to be served by these services.

Qali Id:

People trust institutions that do what they say they will do. That makes a lot of sense. And while Heidi agrees, she also thinks that the impact of COVID should not be taken lightly.

Heidi Larson:

It's one, trust in the ability of an individual or a institution or a government to deliver on what they say they're going to deliver. And the second is their motive. Is their motive really in my best interest or are they just trying to make another dollar? And I have to say, also coming out of COVID, we are not taking seriously, I think, the level of emotional fragility that we have in the planet right now. And that has huge implications. for people's confidence in systems, their reactivity, you know, how quickly they react. Also, uh, we've had a significant negative knock on effect on vaccines in particular because people felt like they were pushed to have vaccines they didn't really want and so they got it because it helped them see their friends at a restaurant or go to a cafe or go to a sport event or something but they resented it and said that's it for me on vaccines. I did it because I had to. And particularly, we see in our research in the Vaccine Confidence Project, the 18 to 34 year olds. And to me, that's a real worry because 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 to pay attention to is historically with vaccines, we've been so hyper focused on getting the jab, you know, counting the numbers and not the context.

Qali Id:

And when we focus on trying to increase vaccine uptake without considering the context, what people have endured, how their trust has been broken and how their feelings have changed, we might do more harm than good. Here's Heidi again.

Heidi Larson:

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 will really not help the equity agenda is the premise that people are doing something wrong and that, you know, we're here to change their minds. In the case of zero dose children, children who have yet to receive any routine immunization, how can social and behaviour change approaches help? Now, sometimes they're zero dose because they haven't had access to those vaccines, but in many cases, as you know, there's also this dimension of, well, they did have access, but they didn't trust it, or they weren't sure they wanted it, or they, you know, were upset that this is the only thing you're coming to them for when you're not taking care of their water, and you're not, you know. We are one of many different health interventions that are knocking on people's doors, and sometimes, you know, they've had enough during that week or day or month. You know, it's like, Oh, you too. So I think the more we could get on the side of particularly the people that we're trying to reach is super important because when people think that you actually care about where they're coming from, that's already a trust builder.

Qali Id:

And here we are, back to trust again. Heidi described a case where people may not want to take the vaccine because they don't feel cared for in other ways. If you listened to our system strengthening episode, you might remember the example in Basra, where the community refused to resolve their water scarcity issue because they felt their government was not supporting them in so many other ways. Let's go back to Francine.

Francine Ganter:

We really need to think about the system as a whole. And what are the ways in which governments and immunization partners really need to show up for people in communities and really demonstrate that we are delivering results for better health, for better prospects, better futures, so that we're rebuilding that trust, right? And not just, let's say, sending out messages about how vaccines are safe, because that's not going to have the impact we need it to have. It's really about showing what we do beyond immunization.

Qali Id:

That's our show. Thank you to Heidi, Saad and Francine for sharing their insights and perspectives from working in immunization across a variety of contexts. You can learn more about them and access links to research and other resources they've shared in our show notes. There you can find a link to UNICEF's first ever programme guidance filled with a library of guides and tools to help anyone understand and implement SBC for Children. If you prefer a page turner, then you might want to check out UNICEF's latest issue of Change Magazine, Why Don't You Just Behave? The publication distills the past, present, and future of social and behaviour change for children at UNICEF and beyond. It has case studies, articles, cartoons, and even a crossword to help experts and non experts understand the role of SBC in the challenges that lie ahead. You can find all the details in our show notes. Thank you so much for listening.