Childhood Vaccination: Science and public engagement in international perspective

1
Childhood Vaccination Science and public
engagement in international perspective

• James Fairhead and Melissa Leach
• With Mike Poltorak, Mary Small, and Jackie
  Cassell

2
Vaccine anxieties

• Current controversies MMR in the UK, Oral Polio
  Vaccine in West Africa
• Encounters between
• Rapidly advancing, globalised health technology
  and technocracy
• Deeply intimate, personal and social world of
  childrearing
• Inevitably, childhood vaccination has become a
  key issue around which debates over public trust
  in science and technology proliferate

3
Explaining vaccine anxieties sedimented terms
of debate

• North-South 'Northern' concern with vaccine
  risks as a luxury amidst forgotten diseases
  (risk society) vs. Southern concern with
  accessing vaccines for still-ravaging diseases
  (underdeveloped society?)
• Class Middle class anxst vs. compliant poor
• Rationality Irrationality vs. rationality
  (rising scientific rationality in South, rise of
  irrationality in North)
• Information Knowledge deficit and misinformation
  vs. education and responsible media
• Emotion Emotion (personal choice) vs. reason
  (evidence-based governance)
• Trust Vaccine anxieties as part of a generalised
  breakdown of trust in public institutions

4
Excavating terms of debate

• Contrasts and stereotypes which pass for
  explanation of vaccine refusal can be seen as
  rooted in scientific and public health
  frustrations with non-compliant publics, and
  research framed by these. But do they hold up?
• What about parents perspectives? How are those
  in Britain and Africa thinking and deciding about
  vaccination, amidst diverse personal experiences,
  cultural knowledges and perspectives, social
  relations, and experiences of national and
  international institutions?

5
Research aims and questions

• Overall aim To develop comparative insights into
  emerging science-society relations in European
  and African settings which have conventionally
  been theorised very differently
• Core questions
• How are public concerns with vaccination socially
  differentiated and shaped by diverse conceptual
  frameworks and knowledges around infection,
  disease and immunity, and experiences of the
  state and of science in other domains?
• How do different people consider trade-offs
  between social and individual benefits and risks,
  what differentiated notions of community and
  communities of trust do these imply, and how
  does this influence organisation around
  vaccination?
• How do vaccine scientists and public health
  professionals conceive of public perspectives
  around vaccination, its research and delivery,
  and how do frontline staff mediate
  professional/ public views?

6
Approach, sites and methods

• Meta comparison Britain West Africa
• Routine and research Engagement not just with
  routine vaccination, but with vaccine science and
  scientific controversy (Science cases MMR in UK,
  MRC vaccine trials in Gambia)
• Sites
• Brighton (Low MMR uptake c. 60)
• Urban and rural Gambia (Relatively good
  infrastructure/access)
• both enable demand issues to be discerned
• Methodology Integrating qualitative
  quantitative methods

7
Collaborative context

• UK
• Collaboration with Brighton and Hove PCT
• Multi-stakeholder Advisory Group
• Local Research Ethics Committees/NHS approvals
• Gambia
• Collaboration with MRC Laboratories
• Pneumococcal Vaccine Trial
• Joint MRC/Government Ethics Committee
• .Balancing work with policy institutions, and
  independent research agenda

8
Ethnography

• Narrative interviews (child health and
  immunisation biographies) 47 Brighton, 100
  Gambia
• Participant observation in social settings where
  parents take infants
• Group discussions
• Health worker interviews and shadowing

9
Surveys

• Building survey questionnaires from emergent
  ethnographic themes to assess significance across
  social variables
• Sampling
• Brighton 1000 children 15-24 months randomly
  selected from Child Health Database, 500 having
  and 500 not having received MMR, plus 135
  complete non-vaccinators
• Gambia 1600 children 12-24 months (800 urban,
  800 rural) selected by random walk in
  randomly-selected census clusters
• Data collection
• Brighton postal, mothers and fathers
  questionnaire, two waves (40 mothers, and 30
  complete non-vaccinators, responded)
• Gambia face-to-face interview of mothers
• (near total response rate)

10
Brighton findings
11
Brighton ethnography indicated

• Anxiety across class importance of confidence to
  go against professional/social expectations
• Parental rationality rooted in childs specific
  health, behavioural, and genetic history not
  generic ideas of risk
• Vaccination outcomes depend not on a singular
  deliberative calculus which information might
  influence, but on unfolding personal and social
  circumstances into which information plays
• MMR talk as a social phenomenon, articulating
  parenting values and ideas of responsibility
• Social acceptance of those who decide
  differently tolerance of personal choice (not
  intolerance of free-riders)
• People rarely speak in terms of trust (in
  science, state, doctors etc) but assume personal
  responsibility and blame (for consequences of
  both vaccination non-vaccination)

12
Brighton survey found

• No significant difference in MMR acceptance
  between graduates and non-graduates (proxy for
  class)
• Media exposure and information sources did not
  differ significantly between MMR acceptors
  refusers (includies delayed/single jabs)
• Almost all (94 acceptors and 77 of refusers)
  thought measles a very or quite serious disease
• When deciding about MMR, only 12 considered
  possible benefits for other children (no
  significant difference acceptors/refusers)
• 81 felt strongly that the most important thing
  is that parents have the choice (a view shared by
  73 of acceptors)
• Only 10 strongly agreed that it is the
  governments responsibility to decide whether
  children should be vaccinated.
• 65 overall were suspicious of the influence of
  pharmaceutical companies (significantly more
  refusers, but even 51 of acceptors)
• Significantly more refusers expressed a general
  distrust of government over science, stopped
  eating beef because of BSE, and check food labels
  for GMOs but these still apply to 30-60 of
  acceptors

13
Strongly associated with MMR refusal are

• Early engagement with the issue (thinking about
  MMR before birth 23 acceptors but 57
  refusers refusal of Vitamin K at birth)
• Personalised view of immunity (belief that
  weakness in child can lead to serious MMR side
  effects - 18 acceptors but 55 refusers strongly
  agreed concern about family health history)
• Ideas about immune system susceptibility (MMR is
  too much in one go - 21 acceptors but 86
  refusers strongly agreed better to get immunity
  naturally 5 acceptors but 46 refusers
  strongly agreed)
• Use of homeopathy - 9 acceptors but 21 refusers
  had consulted a homeopath about their child
• ..Suggests overall significance of age of
  immunity. Implications of correspondence with
  certain strands of MMR science for how
  controversy is playing out?

14
Gambia findings
15
Gambia routine vaccination

• Sedimented professional views
• Vaccination acceptance reflects modern
  biomedical knowledge
• Clinic as positive social occasion
• Defaulters as ignorant, or with wrong priorities
• Compliance/default reflects personal beliefs and
  attitudes

• Contrasting ethnographic findings
• Immunisation integrated with diverse practices to
  promote infant health
• Clinic as place of worry and exclusion for some
• Default for exceptional reasons, compounded
• Clinic attendance negotiated within social
  relations

16
Gambia survey indicated

• More default in urban (28) than rural (18)
  areas, suggesting social integration with health
  delivery more important than geographical access
• High urban default is associated with a cluster
  of poverty-related variables (poor-looking
  compound, tenants, low education, lack of mobile
  phone) factors ethnography suggests are linked
  to forms of exclusion and compounding of problems
  at clinic
• Mothers education makes no difference to
  default in rural areas, undermining assumption
  that high vaccination uptake reflects modernising
  knowledge and rationality

17
Gambiavaccine research
18
Gambia vaccine research

• Sedimented professional views
• MRC research as distinct scientific activity
• Acceptors have understood study aims (informed
  consent), refusers have misconceptions
• Acceptance (or not) reflects relative trust in
  MRC and appreciation of science and modernity

• Contrasting ethnographic findings
• MRC as one amidst many health providers
• Little understanding of study aims decisions
  reflect broader experiences of MRC as an
  institution
• Acceptance (or not) reflects calculus of benefits
  vs. danger, negotiation, and social/power
  relations

19
Gambia ethnographyemergent themes

• Individual infants have unique pathways through
  diverse physical, social and spiritual hazards
  that can afflict them and compound each other
• Complementary ways to build the strength and
  protection that infants need herbalism islamic
  amulets clinic medicine vaccination
• Core ideas concerning strength and wellbeing
  centre on an economy of blood and body fluids
• Engaging with MRC involves balancing its
  strength-giving vaccines and medicines with its
  stealing of blood

20
Some comparative reflections

• Parents think about and discuss vaccination
  issues as part of wider reasoning concerning
  child wellbeing, which interplays with intense
  parental observation and evaluation of a childs
  particular health history, strength and
  vulnerability
• Public engagement with (globalised) vaccine
  technologies is strongly mediated through this,
  rather than being more straightforwardly a matter
  of political imagination of, and trust
  in/distrust of, state, corporate and global
  institutions
• Debates and controversies about vaccine science
  are playing into an age of personalised immunity
  in Britain, and an age of blood in West Africa,
  and thus laying the ground for further
  controversy

21
.....

• Similarities across Gambian and British settings
  undermine dichotomies which cast Southern
  societies as becoming biomedicalised,
  post-traditional, and rational/modern, and
  Northern societies as becoming de-medicalised,
  post-modern and more irrational.
• Science-policy approaches, even those seeking
  participation, deliberation and dialogue, need to
  appreciate such dynamics or they can badly
  misfire.