Childhood Vaccination in West Africa
Vaccines for children are currently high on international policy, aid and funding agendas, as a major promised means to meet the Millennium Development Goals. Yet major challenges have emerged in ensuring effective coverage and dealing with public anxieties.
As a point where globalised technologies meet the personal, social and cultural worlds of infant care, vaccines offer a highly illuminating lens on how people are engaging with science. IDS, together with a range of co-researchers and collaborating partners, has recently completed two linked, comparative projects concerning the changing relationships between science, technology and society in Britain and West Africa, focusing on the issue of childhood vaccination. Details of the first project follow. For details of the second project, see the Childhood Vaccination: an International Perspective project page.
Given current global policy and funding priorities to expand infant immunisation, yet falling coverage rates in many African countries, this research explored the factors shaping immunisation delivery and acceptance in contemporary African health systems. It took a distinctive anthropological approach to explore how parents' own perspectives and experiences, embedded in broader cultural and political processes, shape immunisation demand, supply and interfaces with providers. Ethnographic research examined local vaccination cultures in The Gambia, the Republic of Guinea, Nigeria and Sierra Leone, drawing comparative lessons for improving vaccine delivery and health promotion approaches, and for dealing with so-called 'anti-vaccination rumours'.
Through its collaborative and comparative approach, the project has been supporting and informing immunisation programmes and related communication efforts, and building regional capacity in analysis and practice concerning the cultural dimensions of technology delivery.
Context and summary findings
Much policy deliberation focuses on immunisation supply, highlighting problems of primary health care infrastructure, financing and management. Yet people do not necessarily attend even when immunisation is accessible, underlining the need for complementary understanding of vaccination demand. Whereas policy and health promotion approaches often link low demand or negative 'rumours' about vaccines to assumed public ignorance or misinformation, anthropological approaches link varied demand to how vaccination engages with existing knowledges, aetiologies and perceptions of disease, and specific socio-cultural contexts and experiences of interaction between people and health care providers ('local vaccination cultures').
This research combined medical anthropology, science studies and perspectives on development interfaces to explore how vaccine supply-demand dynamics are shaped by cultural and political processes. Ethnographic research using participant observation, narrative interviews and biographies combined with surveys explored these issues in urban and rural settings in the Gambia and Guinea. This was followed by comparative research and regional policy networking extending to Nigeria and Sierra Leone.
Research findings included:
- Most mothers have culturally-grounded active demand for vaccination based on non-biomedical concepts of the body and vaccine actions - preventing and 'chasing out' disease, promoting strength and weight, and complementing Islamic and herbal protection.
- Strong social demand for vaccination is manifested in group clinic attendance, social networking and singing. Yet some poorer, immigrant mothers feel excluded.
- Misconceptions about when a child is completely vaccinated are common, exacerbated by mistaken counting of National Immunisation Days as part of schedule completion.
- Vaccination default or lateness less reflects the social variables often highlighted in health worker discourses (education, wealth, ethnicity) than haphazard problems (e.g. family events, illness, travel) and intra-household relations that can affect anyone.
- Rumours that vaccines cause sterility, violence and paralysis circulate, but have led to mass refusal only when (a) top-down, coercive campaigns are privileged amidst weak routine services; (b) technological practices intersect with cultural conceptions so that anxieties 'make sense'; (c) providers' motivations are interpreted within prevalent political tensions, and (d) influential individuals and media networks operate. Such conditions prevailed in northern Nigeria in 2003-4.
- Vaccination coverage problems largely reflect interactions between supply and demand: Mothers are put off by walking long distances only to find no vaccines available, or by being berated by frontline workers for late or missed appointments.
- A proliferation of private providers is undermining already weak, decentralised state vaccination services, by competing for curative services and thus undermining health centre financing. Practices of informal charging for vaccination are common, and exclude the poorest.
Policy-relevant lessons include:
- Health promotion approaches should be based on dialogue which builds on cultural understandings of vaccination value, and focuses on understanding vaccination schedules and their completion.
- Writing-off rumours as illegitimate misconceptions, or attempting to vanquish them through education, will be ineffective unless their root causes in cultural and political dynamics are understood and addressed.
- Supply-demand dynamics underline the ongoing need to strengthen primary health care systems to ensure effective vaccine delivery, including local public-private-community partnerships and better integration of NIDS and routine immunisation.
- The training and supervision of frontline health workers needs to attune them to the actual reasons for vaccination default - in day-to-day and social relational problems that can affect anyone, and in social worries and marginalisation at the clinic for a few - so they can develop more sensitive and encouraging delivery practices.
A regional workshop held at the MRC Laboratories, Fajara, The Gambia in June 2005 brought together social scientists and policy-makers from the four countries to draw out comparative insights and questions. Given the interest generated by the research approach and comparative workshop discussions, participants have joined to establish an ongoing West African Social Science and Immunisation Network (WASSIN). This is currently being developed, with the aim of providing a forum for exchange and discussion of West Africa-relevant social science analysis of ongoing challenges in immunisation.