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TRANSCRIPT
The Role of Health Teams in Achieving
a Successful Vaccination Campaign
ANA MARÍA MORALES
The Role of Health Teams in Achieving a Successful Vaccination CampaignAna María MoralesJournalist and Communications Director, Institute of Public Policies in Health, San Sebastian University (IPSUSS), Santiago, Chile
Introduction
Are vaccines dangerous? Since Edward Jenner first entered this field through inoculation, and later on when
Louis Pasteur invented the first laboratory vaccine, there have always been critical voices second guessing their
safety and efficacy.
The fear of the unknown and the potential side effects were part of the arguments used in the anti-vaccine
campaigns at the beginning of the XIX century.1
In his work, The cow-pack or the wonderful effects of the new inoculation, in 1802, the English cartoonist
James Gillray represented how sensitive this topic was for the citizenry (Figure 1). Later on, when England
approved mandatory child vaccination in 1853 and imposed fines or even imprisonment on parents who
refused to have their children vaccinated, new counterarguments emerged, such as whether this measure was
a violation of the individual rights of people. In the early 1900’s, the first anti-vaccine leagues were born in New
England and New York.
Figure 1. Cartoon by James Gillray: The Cow-Pack or the Wonderful Effects of the New Inoculation (1802)
That debate is not very different from
the existing one. When analyzing news
headlines, in the various countries of the
region, it is possible to see the resistance
against vaccines (Figure 2). In particular,
this is due to dissenting opinions amongst
the political actors, opinion leaders and
technicians in this area, who act as points
of reference for the public.
Source: British Museum
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Figure 2. Vaccination Headlines in the Press in Latin America
This resistance is influenced by various factors: the decrease in risk perception of
diseases prevented by vaccines; overloaded immunization programs whose need
has not always been properly communicated to the public; greater knowledge about
side or adverse effects as well as accidents or errors in supply; pressure of opinion
leaders; lobbying by anti-vaccination groups and mistrust toward pharmaceutical
companies.
The media and social networks play a remarkable role in this situation, acting as a
sounding box, sometimes by disseminating information of dubious or contradictory
origin which impacts the decision-making process of the population.
All these elements contribute to a certain apprehension toward the health system,
represented by suppliers and policy makers.
In 2013, an example of the impact of anti-vaccination lobbying campaigns was
seen in Chile with the passing of the law prohibiting thimerosal as a preservative
in vaccines. The influence of these sectors resulted in a group of parliamentarians
from different political paths to present a bill that was approved by Congress,
notwithstanding the fact that stewardship around this issue belongs to the Ministry of Health. The initiative was
voted on without consideration for the concerns raised by the Pan American Health Organization (PAHO) and
the scientific associations.2 The law had to be vetoed by the President of the Republic; however, it led to a loss
of confidence in the national immunization program. This led to a decrease in coverage figures and, in many
cases there were legal disputes between parents who refused to have their children vaccinated and the health
services, which had to be settled in court.
ENGLISH TRANSLATIONS
1. Robert de Niro
controversially
supports
anti-vaccine
documentary.
2. Audit reveals
mistakes in Human
Papillomavirus
vaccination in RM
3. Scientist argues the
existence of links
between a vaccine
and autism.
4. Cancellation of
papilloma vaccines
at schools due to
rejection.
5. Ten communities
ignored the
recommendation to
vaccinate pregnant
women against
whooping cough.
6. Chile will be the
first country to pass
a law excluding
thimerosal.
7. More than 200
arrests in expired
vaccine scandal in
China.
8. Vaccines are
dangerous.
9. Jim Carrey stirs
controversy due
to criticism against
vaccines.
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Another well-known example includes recent events in Colombia with the introduction of the human
papillomavirus (HPV) vaccine. Opposing population groups, including support by religious sectors and
opinion leaders, argued unfoundedly that HPV vaccination in pre-adolescent girls would imply some sort of
permissiveness for early sexual initiation, which became a flag for their fight. This resulted in improper coverage
amongst the target group. Similar situations were replicated later on in other countries of the region.
A dominant factor contributing to this issue is the low-risk perception associated with vaccine-preventable
diseases, a situation that is shared in several countries of the Americas. In particular, this issue stands out within
sectors of the population that have the highest level of education or income, and have ceased to vaccinate their
children because they do not consider it a preventive action, such as the case with the bacille Calmette-Guérin
(BCG) vaccine. This is an alarming trend in a region where tuberculosis is still an existing public health problem,
and where the lack of acquired immunity from the vaccine may lead to more severe occurrences of the disease.
The Art of Persuasion
Trust in the immunization programs is not infinite. The successful actions carried out in recent decades to
control diseases such as smallpox or poliomyelitis are no longer sufficient as prevention policies.
Consequently, influenza vaccination coverage in adults over 65 years, in most countries, and in particular, in the
most developed countries, does not reach 80%, as reported in the 2015 Health Indicators of the Organization
for Economic Cooperation and Development (OECD). The success of a campaign depends in part on the level
of protection attained for its vulnerable population.
For individuals to be willing to be vaccinated, they need to understand that the benefit will be greater than the
cost of vaccine administration. Cost is not understood in monetary terms since the vaccines included in the
immunization programs from the various LAC countries are usually provided free of cost. Rather, cost is viewed
in terms of time spent on transfer, waiting, pain, some adverse effect, and/or a small scar on the arm.
How can this objective of vaccine uptake be attained? Based on the cultural changes that happened over recent
decades, the response is for people to not only be convinced of the value of vaccines for them or their children,
but also inclined to opt freely for vaccination.
Currently, there is a greater demand for information. Communities demand trustworthy and specialized
evidence regarding vaccines. There is greater social control on State policies and this transcends borders. For
the immunization programs this accounts for a true cultural revolution because there is a need to shift the
paradigm used over recent years, mainly to change the way public health communication takes place.
Failing to address this demand for more information has very high costs and immediate consequences for the
authorities or the officials who have a public role to fulfill.
It is essential for health sector workers to communicate effectively. Whenever problems are not anticipated,
there is no capacity to control them. The health of the population is strictly related to access and use of
information. However, information is not always available or it is not available in the proper form or of high
quality. Examples from the situation with the HPV vaccine in Colombia are telling.
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The most common mistakes made by the technical teams from the health sector entail assuming that
“individuals know” the importance of vaccination while health illiteracy amongst the members of our
populations is high, in particular amongst the groups with the lowest school attendance.3
The other mistaken assumption is that whatever worked in other countries is perfectly applicable to the local
situation, without considering the distinct idiosyncrasies at the local level. For example, the inclusion of a new
vaccine in an immunization plan, such as the HPV vaccine, without previously assessing all local scenarios
is setting up for failure. Cultural resistance by the most conservative groups of the population, the religious
sectors, the indigenous peoples, the anti-vaccination organizations, the youth who are the target population for
vaccination or even the offensive by the pharmaceutical industry itself, must be considered in advance.
If there is no rapid response capacity by the technical teams or the authorities, uncertainty and disinformation
will influence the opinion of citizens and regaining public trust becomes extremely difficult. Typically after such
situations, vaccination coverage does not reach the expected levels to guarantee the protection of the target
population, as well as the cost-effectiveness of the measure.
Paradigm Shift
It is erroneously believed that the population should be informed or educated through communications
campaigns with a spot on television, phrases on radio programs or information handouts. These approaches are
all merely instruments of a global strategy.
A paradigm shift involves abandoning that school of thinking and reformulating the way things are done. It
should be understood that it is not only a matter of knowledge but also beliefs. The communications strategy
should then be focused on stimulating, listening, learning and transferring responsibility for self-care to the
public.
The success of a vaccination campaign is conditioned by the responsibility people undertake to care for their
own health, which is strongly determined by the educational level they have attained and that of their family
environment. This is where there can be a significant inequality gap.
Individuals with low educational levels or poor health literacy are at greater risk of mortality, visit emergency
rooms more frequently due to a decompensation or severe impairment of their health (a condition that may
be irreversible in some cases) and have a higher-than-average hospitalization rate. Preventive care, such as
vaccinations or tests, is less frequent in these individuals.4
Therefore, there is a need to create opportunities for education. In the area of health care, teams of practitioners
make efforts to educate the population through promotional activities or during medical visits. However, this is
not always compatible with the demands of their work and the fulfillment of the health goals imposed on them.
Often times, targeting coverage indicators rather than education or health care quality indicators becomes the
priority.
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The communications strategy for a vaccination campaign should be complemented with the following:
� Review the situation before introducing a new vaccine into the immunization plan or changing a pre-
established schedule.
� Identify the problems and implement actions to anticipate an eventual challenge by other stakeholders
opposing the measure. Within this context, assess the level of prejudices in connection with the vaccines
within a specific population. Information disseminated on the radio, television and social networks
reaches everyone. It is naive to think that detractors of the vaccine have not done their homework.
� Define a work strategy with constant communication strategies to create conditions fostering a policy
change and a constant assessment of the actions.
� Identify strategic allies or partners to technically endorse the work being developed, such as international
agencies (WHO, PAHO, CDC, other Ministries of Health of the Region), scientific associations,
professional associations, civil society organizations or other public or private agents, to have them
participate in the campaigns and speak independently.
� Design the health network so that every technical team manages the same information promptly;
determine the tasks to be completed by the authorities and technical officials on the field.
� Design an activity program. The launch of a vaccination campaign is not sufficient. A set of actions to be
sequentially implemented is required. Hold a press conference to provide context for the significance of
vaccination and show cases of people impacted by the disease or the adverse effects; visit various health
centers to verify immunization coverage and focus the message on the groups that are lagging the most;
add credible spokespersons supportive of the initiative to the campaign.
� Promote strategies that bring vaccination closer to people, through discussions at schools or other
educational institutions, grassroots organizations, elderly care centers or patient associations for
individuals to ask questions and have their doubts answered.
� Vaccination on the field. Reach out to the target group rather than wait for the target group to go to
the health clinic. Depending on the intended target population, this can be achieved through mobile
vaccination units, visits to neonatal wards, preschools, schools or elderly care centers.
� Educate and constantly deliver information not only through the national media outlets but also through
the community media outlets to reach out to the public. Provide communications material for them to
use, promote interviews with technical spokespersons as part of mass programs on radio stations; and
develop key messages that can be replicated on social networks and web pages.
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Conclusion
To sum up, maintaining a population protected against preventable diseases for which effective vaccines
have been developed requires a profound change in the way things are done. Effective communication
and leadership amongst workers in the immunization programs are the most important. Work in the field is
an inescapable requirement as well as the knowledge of the population and their acceptance level of the
immunization plan. Prior to the vaccination period, the strategies described in this chapter should be developed
to excite, convince, and relate to community leaders. Each and every one is different from the next.
When communicating, the following is important to keep in mind:
� Concerns expressed by individuals need to be addressed in form and substance, and this entails active
listening.
� Use straightforward language.
� The message being conveyed needs to be straightforward and clear. Define key phrases for people to
remember, in particular, the importance of protecting the family.
� The spokesperson needs to be credible, empathetic, and honest when faced with an adverse situation.
Challenges need to be acknowledged.
A poorly-planned vaccination campaign- without awareness for the cultural environment or strong local leadership-
may risk failing to reach minimum coverage levels. A failed program will not only lead to direct losses in personnel
time, cost of vaccines and supplies, but also a great indirect cost: the emergence of cases of the disease intended to
be prevented, discredit for the health authority and uncertainty about the program as a whole.
References
1. Robert M Wolfe, assistant professor and Lisa K Sharp, assistant professor. Anti-vaccinationists past and present. https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC1123944/
2. Statement on the elimination of the multi-dose vials of vaccines containing Thimerosal. Chilean Journal on Infectology 2013; 30 (4):
346-349. http://www.scielo.cl/pdf/rci/v30n4/art01.pdf
3. Monsalves, MJ., Durán, D., Romero, MI., Mañalich, J., (2015). Health literacy amongst chronic patients served in primary care, in four
Chilean communities. In the XXXII Chilean Meeting on Public Health. Santiago, Chile.
4. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E,
Wallace I, Viswanathan M. Health Literacy Interventions and Outcomes: An Updated Systematic Review. http://www.ncbi.nlm.nih.gov/
pubmed/23126607.
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