Public Trust in Vaccination: An Analytical Framework

"Unwillingness to be vaccinated is a growing problem in the developed world. This trend is gradually emerging in several parts of India as well."

With a focus on the Indian context, this paper develops an analytical framework to assess trust in vaccination. The framework considers trust in vaccination from four perspectives - trust in: the health system, the vaccine policy, vaccination providers, and specific vaccines. The framework considers specific issues involved in vaccination trust, including increasing scepticism towards medical technology, perceptions of conflicts of interest in the vaccine policy, the presence of strong alternative schools of thought, influence of social media, and lack of transparency and openness. The paper concludes by arguing that engaging with communities and having a dialogue about the vaccination policy is an ethical imperative.

In the paper's introduction, author Vijayaprasad Gopichandran explains that, while the public health system in India is grappling with issues concerning the supply side of the vaccination programme, there are important issues concerning the demand side that also need to be considered. In certain areas of the country, despite having easy access to vaccines, parents are hesitating to follow even the routine immunisation schedule for their children. Factors such as heightened awareness of the profit motives of the vaccine industry, conflicts of interest among policymakers, and social, cultural, and religious considerations have eroded the people's trust in vaccination and contribute to vaccine hesitancy.

In light of the fact that decision-making regarding vaccination, especially in developing countries such as India, is very complex, Gopichandran presents a proposed decision-making model in Figure 1. Parents are provided information on vaccination by various sources, the most common being healthcare providers. This information is supplemented by information based on the experience of community members and by the media, including social media. In addition, among the less educated and rural populations, rumours are a potential source of information. All these sources create awareness (sometimes incorrectly) of vaccination. While educated and motivated people may access the relevant information through the internet and social media and appraise it, the large rural population, whose educational attainment and health literacy levels are poorer, is not actively involved in healthcare decisions and shows passive conformism based on popular practices and trends. In certain underdeveloped areas, coercion and force are used to get people vaccinated. These people cannot be said to have made an informed vaccination choice.

Several social, political, economic, religious, and cultural influences play a role in determining the acceptance of vaccines. Trust, too, is influenced by sociocultural and political factors. On the one hand, there are those who accept vaccines rationally, on the basis of active engagement with the vaccination system. On the other hand, there are people who are at various stages of vaccine hesitancy, ranging from total rational rejection, partial rejection of specific vaccines, passive conformism, and passive misinformed rejection.

Against this background, Gopichandran explores the concept of trust in vaccination. Among the points he makes (which are illustrated in Figure 2):

• A trustworthy policy on vaccination is one that is transparent, engages with the communities, and is open to dialogue. For example, before introducing a new vaccine, modifying the schedule, or changing the route or mode of administration, policymakers should engage with the communities and discuss the potential implications of such a change.
• Trust in the health system involves perceptions of the quality, competence, fairness, and openness of the system. In India, while the level of trust in the public system may be low because of the perception that it lacks competence and quality, there may be doubts about the private system because of the profit motives and conflicts of interest involved. Trust in the health policy and health systems is institutional in nature and, therefore, difficult to negotiate through interpersonal interactions.
• The level of trust in vaccination providers is reflected in the people's perceptions of their competence, honesty, fidelity, and confidentiality. The trust people have in their healthcare providers strongly influences their trust in vaccination, since healthcare providers are the primary source of information on vaccinations for most people. Trust in the vaccine provider, doctor, nurse, or community health worker can be negotiated through active dialogue.
• The overriding factors determining trust in specific vaccines are those of efficacy and safety. Vaccines carry with them reputations that are based on reports of successful prevention of diseases and adverse events following immunisation (AEFIs). AEFIs lead to the erosion of trust in the specific vaccine. Given that no vaccine is completely free of adverse events, the vaccination policy should feature a sound surveillance system to detect AEFIs, and make provision for timely intervention and mitigation of the consequences.
• "It is important to note that high vaccination coverage does not necessarily reflect trust in vaccination."

Having reflected on the role of trust in vaccination in the decision-making process and the framework of trust in vaccination, Gopichandran addresses specific issues pertaining to mistrust in vaccination. To cite only one example, with the advances in information and communication technology (ICT), "Misinformation about vaccination spreads as fast as, or sometimes faster than, credible information. In certain districts of Uttar Pradesh and Bihar, there was serious resistance to the polio vaccination due to widespread misinformation among the minority communities that it was a western ploy to sterilise the minority populations and thus reduce their numbers....A deeper analysis of the social reasons for resistance to the polio vaccine in Uttar Pradesh revealed that other than the 'misinformation' factor, the community was tired of the repeated rounds of the pulse polio campaign, which had led to suspicions, and the minority community was even less amenable to vaccination because the complete apathy of the mainstream health system towards their other healthcare needs had left them feeling marginalised and oppressed....This highlights how trust in vaccination is strongly influenced by trust in the health system and the social, historical and political context."

Gopichandran argues that active community engagement is one of the key measures for ensuring that the vaccination policy and health system are viewed as trustworthy...Trust is a double-edged sword. Too much trust, ie blind and unquestioning trust, can push people into a vulnerable position, while too little trust can keep them from participating in and reaping the benefits of public health interventions. To empower people with the right type and amount of trust, it is an ethical imperative to engage in a dialogue with the community..." Active community engagement with respect to vaccination policies can include:

• involving community representatives (parents of children in the relevant age group) in vaccination committees to hear their opinions and engage them in policy decisions;
• establishing a horizontal dialogue with communities during the introduction of new vaccines, change in the vaccination schedule, trials of experimental vaccines, etc., and not just focusing on the provision of information;
• instituting community-based vaccination surveillance, in which data on the incidence of vaccine-preventable diseases, vaccination coverage, and AEFIs are collected and reported by community members;
• facilitating responsible engagement of community champions who spearhead the movement for the dissemination of credible, authoritative information on vaccines;
• adopting a judicious approach to informing the community about AEFIs so that panic is not created and, at the same time, appropriate information is disseminated, ensuring transparency;
• establishing appropriate mechanisms of accountability with the participation of community members, who should be empowered to question vaccination practices and make informed decisions for themselves; and
• creating community ownership of the health of the children and their own future, and empowering communities to demand vaccination services and not act as just passive recipients of vaccinations.

"The objective of appropriate community engagement is not just to increase the acceptance of vaccines, but to promote a sense of self-determination that would allow the community members to make well-informed decisions on which vaccines to accept and reject for their children. To sum up, community engagement is an ethical imperative to help people realise their right to good health."