Vaccine hesitancy: Definition, scope and determinants

Vaccine hesitancy: Definition, scope and determinants Noni E. MacDonald

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Vaccine hesitancy: Definition, scope and determinants 2015 Vaccine 10.1016/j.vaccine.2015.04.036 macdonald2015-vaccine-hesitancy-definition-scope macdonald2015-vaccine-hesitancy-definition-scope.txt, the project's staged copy 34567a316f0fcc2f39cae5eaa987cb405c30a725 cc-by social-sciences

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0 spans located by searching the stored text for the quote's exact words, allowing any whitespace between them THE TERM ITSELF - what 'vaccine hesitancy' should be taken to mean, what it must exclude, and what factors belong under it; produced by a WHO SAGE working group over three years Quotation withheld because this record is not cleared for redistribution. what to call the phenomenon, where its boundaries fall against system failure and against low demand, and how to group the factors that drive it Quotation withheld because this record is not cleared for redistribution. a definition adopted by WHO, plus the Vaccine Hesitancy Determinants Matrix - and, unusually, THE DELIBERATION: which candidate terms were rejected and why Quotation withheld because this record is not cleared for redistribution. method Quotation withheld because this record is not cleared for redistribution. delay or refusal of vaccination where services are available - a behaviour lying on a continuum between full acceptance and outright refusal, and heterogeneous everywhere between Quotation withheld because this record is not cleared for redistribution. expert-consensus expert-consensus Quotation withheld because this record is not cleared for redistribution. the paradox the definition has to accommodate: `Immunization programme success may, paradoxically, result in complacency and ultimately, hesitancy`, because the risk of the disease falls out of view as the vaccine works. The determinant is generated by the intervention's own success Quotation withheld because this record is not cleared for redistribution. and the asymmetry that the term must not hide: `When rates of hesitancy are high, levels of demand are low, but low rates of hesitancy do not necessarily mean that demand will be high`. Removing hesitancy does not produce demand, so the two cannot be used as each other's proxy Quotation withheld because this record is not cleared for redistribution. THE NAME WAS CHOSEN AGAINST ITS OWN SEMANTICS AND THE PAPER SAYS SO. `vaccine hesitancy` implies `the core issue is vaccine related`, while `vaccination hesitancy` covers `a much wider range of factors` - and the WG `nevertheless chose to adopt the term vaccine hesitancy but defining it in the broader sense`. The two reasons given are both institutional: SAGE'S OWN TERMS OF REFERENCE, and EXISTING USAGE Quotation withheld because this record is not cleared for redistribution. the word was kept over a stated objection to its connotation - `Concerns were raised that hesitancy has a negative connotation` - and the more positive alternative was rejected on scope rather than on accuracy Quotation withheld because this record is not cleared for redistribution. the definition is RELATIVE TO A TARGET, which makes it a moving quantity: hesitancy is `measured against an expectation of reaching a specific vaccination coverage goal, given the immunization services available`. The same behaviour is more or less hesitant depending on the goal set for the population Quotation withheld because this record is not cleared for redistribution. the boundary against system failure is asserted rather than operationalised: where uptake is low because of stock-outs or conflict, `hesitancy is not the main explanation` - but the paper gives no procedure for deciding, in a given population, which it is. It only says the decision is `ESSENTIAL for the selection of interventions` Quotation withheld because this record is not cleared for redistribution. the model was chosen for COMPREHENSIBILITY, not for fit: the 3 Cs were adopted `As this model was viewed as being the most readily understandable`, and those three words then entered the definition itself. A selection criterion about readers became a property of the concept Quotation withheld because this record is not cleared for redistribution. THE MATRIX WAS BUILT FROM THE SOURCES IT IS LATER CHECKED AGAINST: `determinants identified from research studies, experiences of WG members in the field, and discussions with experts`. The paper does report a completeness check against the commissioned systematic review and the managers' survey, and it comes back empty - but those are two of the same three inputs, so the check is agreement with itself. (The sentence reporting it carries a URL inside each subject and cannot be quoted; see the harness note.) Quotation withheld because this record is not cleared for redistribution. and the Matrix is disclaimed as an instrument: `while not primarily intended as a practical tool, may be helpful` - offered to survey-question developers while declining responsibility for being a measure Quotation withheld because this record is not cleared for redistribution. the funding disclosure sits directly on the concept: the group monitoring `public confidence in Immunization Programs` took research funding from Novartis and meeting funding from GSK, and one author consulted for GSK ON VACCINE CONFIDENCE. Declared, and worth recording because `confidence` is one of the three words in the definition Quotation withheld because this record is not cleared for redistribution. whether the Matrix had missed any determinant - the paper checks it against a commissioned systematic review and a commissioned managers' survey eliminates: little, and the reason is visible in the Matrix's own construction: it was built from research studies, WG field experience and expert discussion, which overlaps the sources it is then checked against. The paper reports the check and claims no independence for it · outcome: partial Quotation withheld because this record is not cleared for redistribution. whether low uptake caused by system failure is being counted as hesitancy eliminates: the confound in principle - 'in these situations hesitancy is not the main explanation' - but no procedure is given for telling them apart in a real population, and the conclusions repeat the warning rather than resolving it · outcome: failed Quotation withheld because this record is not cleared for redistribution. whether hesitancy and demand can be treated as one quantity eliminates: the identification, by a stated asymmetry: high hesitancy implies low demand, and low hesitancy DOES NOT imply high demand · outcome: held Quotation withheld because this record is not cleared for redistribution. whether 'confidence' would have served as the name, tested against scope rather than against sentiment eliminates: the alternative term - it covers 'only one category of factors' - though the objection raised against 'hesitancy' itself, its negative connotation, is recorded and never answered · outcome: held Quotation withheld because this record is not cleared for redistribution. vaccine hesitancy vaccine hesitancy Quotation withheld because this record is not cleared for redistribution. vaccination hesitancy vaccination hesitancy Quotation withheld because this record is not cleared for redistribution. vaccine demand vaccine demand Quotation withheld because this record is not cleared for redistribution. confidence confidence Quotation withheld because this record is not cleared for redistribution. complacency complacency Quotation withheld because this record is not cleared for redistribution. convenience convenience Quotation withheld because this record is not cleared for redistribution. trust trust Quotation withheld because this record is not cleared for redistribution. communication communication Quotation withheld because this record is not cleared for redistribution. determinant determinant Quotation withheld because this record is not cleared for redistribution. vaccine hesitancy determinants vaccine hesitancy determinants Quotation withheld because this record is not cleared for redistribution. social determinants of health social determinants of health Quotation withheld because this record is not cleared for redistribution. Vaccine Hesitancy Determinants Matrix Vaccine Hesitancy Determinants Matrix Quotation withheld because this record is not cleared for redistribution. vaccine hesitancy - THE DEFINITION, VERBATIM: `delay in acceptance or refusal of vaccination despite availability of vaccination services ... complex and context specific, varying across time, place and vaccines ... influenced by factors such as complacency, convenience and confidence`. THREE OF THE FOUR CLAUSES ARE HEDGES, and the operative one is `despite availability` Quotation withheld because this record is not cleared for redistribution. `vaccine` versus `vaccination` hesitancy - THE PAPER'S OWN GLOSS SAYS THE CHOSEN NAME IS THE WRONG ONE: the former `implies that the core issue is vaccine related`, the latter `covers a much wider range of factors`, and the group took the former while meaning the latter. THE DEFINING PROPERTY IS A COMMITTEE DECISION, RECORDED Quotation withheld because this record is not cleared for redistribution. confidence - REJECTED AS THE NAME AND KEPT AS A COMPONENT. `The most commonly offered alternative in the literature`, `a more positive word`, refused because it is `still narrow in scope covering only one category of factors` - and then installed as one of the three Cs inside the definition it lost to Quotation withheld because this record is not cleared for redistribution. confidence, the component - `defined as trust in (i) the effectiveness and safety of vaccines; (ii) the system that delivers them ...; and (iii) the motivations of policy-makers`. Two of the three objects of that trust are institutions, not vaccines Quotation withheld because this record is not cleared for redistribution. vaccine acceptance / uptake - EXCLUDED AS NAMES because `neither captured the concept breadth`, with the worked reason given: `one might accept a vaccine but delay in accepting it`. A term rejected for being satisfiable by the wrong case Quotation withheld because this record is not cleared for redistribution. hesitancy determinants - EXPLICITLY NOT SOCIAL DETERMINANTS OF HEALTH: `education and socio-economic status do not influence hesitancy in only one direction`, whereas as a social determinant `education drives in one direction`. A variable whose sign is not fixed cannot be used the way the neighbouring literature uses it Quotation withheld because this record is not cleared for redistribution. extends → the '3 Cs' model proposed to the WHO EURO Vaccine Communications Working Group in 2011 - adopted into the definition BECAUSE it was the most readily understandable Quotation withheld because this record is not cleared for redistribution. supports → the Global Vaccine Action Plan's Strategic Objective 2, which asks that communities 'demand immunization as both their right and responsibility' - the definition is written to serve a programme goal, not only to settle a term Quotation withheld because this record is not cleared for redistribution. contradicts → the treatment of vaccine hesitancy determinants as social determinants of health, whose variables have a fixed direction Quotation withheld because this record is not cleared for redistribution. confidence —operationalised-as→ trust confidence trust Quotation withheld because this record is not cleared for redistribution. vaccine hesitancy —distinct-from→ vaccine demand vaccine hesitancy vaccine demand Quotation withheld because this record is not cleared for redistribution. communication —distinct-from→ determinant communication determinant Quotation withheld because this record is not cleared for redistribution. vaccine hesitancy determinants —distinct-from→ social determinants of health vaccine hesitancy determinants social determinants of health Quotation withheld because this record is not cleared for redistribution. vaccine hesitancy —contrasted-with→ vaccination hesitancy vaccine hesitancy vaccination hesitancy Quotation withheld because this record is not cleared for redistribution. THE FIELD HAD NO DEFINITION TO REVIEW: `review of the literature did not reveal an established definition` - and the group's first doubt was about the word itself, because `hesitancy has a negative connotation` THE FIELD HAD NO DEFINITION TO REVIEW: `review of the literature did not reveal an established definition` - and the group's first doubt was about the word itself, because `hesitancy has a negative connotation` Quotation withheld because this record is not cleared for redistribution. the group adopted 'vaccine hesitancy' over 'vaccination hesitancy' but defined it in the broader sense, since SAGE used it and it was more widely accepted the group adopted 'vaccine hesitancy' over 'vaccination hesitancy' but defined it in the broader sense, since SAGE used it and it was more widely accepted Quotation withheld because this record is not cleared for redistribution. confidence, the most common alternative term, was judged still narrow in scope, covering only one category of factors confidence, the most common alternative term, was judged still narrow in scope, covering only one category of factors Quotation withheld because this record is not cleared for redistribution. `vaccine acceptance` and `uptake` were excluded because `neither captured the concept breadth`, with the counterexample stated: one might accept a vaccine but delay in accepting it `vaccine acceptance` and `uptake` were excluded because `neither captured the concept breadth`, with the counterexample stated: one might accept a vaccine but delay in accepting it Quotation withheld because this record is not cleared for redistribution. the construct is RELATIVE TO A TARGET: hesitancy is `measured against an expectation of reaching a specific vaccination coverage goal, given the immunization services available` the construct is RELATIVE TO A TARGET: hesitancy is `measured against an expectation of reaching a specific vaccination coverage goal, given the immunization services available` Quotation withheld because this record is not cleared for redistribution. the model entered the definition because it was easy to follow: the 3 Cs were taken `As this model was viewed as being the most readily understandable` the model entered the definition because it was easy to follow: the 3 Cs were taken `As this model was viewed as being the most readily understandable` Quotation withheld because this record is not cleared for redistribution. the Working Group concluded that communication is a tool, not a determinant of vaccine hesitancy the Working Group concluded that communication is a tool, not a determinant of vaccine hesitancy Quotation withheld because this record is not cleared for redistribution. unlike social determinants of health, hesitancy determinants such as education and socio-economic status do not act in only one direction unlike social determinants of health, hesitancy determinants such as education and socio-economic status do not act in only one direction Quotation withheld because this record is not cleared for redistribution. programme success can manufacture the problem: `immunization programme success may, PARADOXICALLY, result in complacency and ultimately, hesitancy` programme success can manufacture the problem: `immunization programme success may, PARADOXICALLY, result in complacency and ultimately, hesitancy` Quotation withheld because this record is not cleared for redistribution. the asymmetry that stops hesitancy being used as a proxy for demand: high hesitancy implies low demand, LOW HESITANCY IMPLIES NOTHING the asymmetry that stops hesitancy being used as a proxy for demand: high hesitancy implies low demand, LOW HESITANCY IMPLIES NOTHING Quotation withheld because this record is not cleared for redistribution. where system failures such as stock-outs or conflict suppress uptake, hesitancy is not the main explanation where system failures such as stock-outs or conflict suppress uptake, hesitancy is not the main explanation Quotation withheld because this record is not cleared for redistribution. the Matrix is offered to survey-question developers WHILE BEING DISCLAIMED AS AN INSTRUMENT: `while not primarily intended as a practical tool, may be helpful` the Matrix is offered to survey-question developers WHILE BEING DISCLAIMED AS AN INSTRUMENT: `while not primarily intended as a practical tool, may be helpful` Quotation withheld because this record is not cleared for redistribution. the LSHTM confidence-monitoring group received research funding from Novartis and meeting funding from GSK, and Heidi Larson consulted for GSK on vaccine confidence the LSHTM confidence-monitoring group received research funding from Novartis and meeting funding from GSK, and Heidi Larson consulted for GSK on vaccine confidence Quotation withheld because this record is not cleared for redistribution. delay in acceptance or refusal of vaccination despite availability of vaccination services; complex and context specific, varying across time, place and vaccines; influenced by complacency, convenience and confidence vaccine hesitancy Quotation withheld because this record is not cleared for redistribution. trust in (i) the effectiveness and safety of vaccines, (ii) the system that delivers them, and (iii) the motivations of the policy-makers who decide on them confidence Quotation withheld because this record is not cleared for redistribution. the state in which perceived risks of vaccine-preventable diseases are low and vaccination is not deemed a necessary preventive action complacency Quotation withheld because this record is not cleared for redistribution. physical availability, affordability and willingness-to-pay, geographical accessibility, ability to understand, and appeal of immunization services convenience Quotation withheld because this record is not cleared for redistribution. the number of Cs - complacency, convenience, confidence - carried from a communications working group's model into a WHO definition 3 Quotation withheld because this record is not cleared for redistribution. education education Quotation withheld because this record is not cleared for redistribution. socio-economic status socio-economic status Quotation withheld because this record is not cleared for redistribution.

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