aharona glatman freedman social determinants sept 4-5 2013 -
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The Effect of Social and Behavioral Determinants on Immunization Programs
Lessons learned from childhood vaccination programs
AERAS September 4-5, 2013
Aharona Glatman-Freedman, M.D., M.P.H. Clin. Associate Professor Department of Pediatrics Department of Family and Community Medicine New York Medical College
Non-biological determinants of
Immunization Programs
What will happen when a new vaccine for TB is available ?
• Introduction
• Public acceptance
• Finance
• Sustainability
Determinants important for the success of Immunization programs
Biological
• Vaccine efficacy
• Vaccine safety
• Epidemiology
Non-biological
• Economy/Finance
• Politics/Government
• Social environment
• Logistics
√
√
√
Determinants important for the success of Immunization programs
Biological
• Vaccine efficacy
• Vaccine safety
• Epidemiology
Non-biological
• Economy/Finance
• Politics/Government
• Social environment
• Logistics
√
√
√
Low Income Countries
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
High- and Middle- Income Countries
• Vaccine safety
• Information/Misinformation
• Internet
• Beliefs (religious, cultural, personal)
• Immigration
• Urban vs Rural residence
• Complementary and Alternative Medicine
• Financial Factors
• Ethical issues
Low Income Countries
Social and behavioral determinants
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
• Childhood vaccines
• Basic vaccines
Polio, Diphtheria, Pertussis, Tetanus, Measles, BCG
Role of social environment Low Income Countries
Availability of immunization services within a walking distance did not always translate to their
usage
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
Low Income Countries
Social and behavioral determinants
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
Maternal education
Low Income Countries
Social and behavioral determinants
Access to higher education
• Household living conditions
• Parental education
• Religious and ethnic groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
Low Income Countries
Social and behavioral determinants
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
Infrastructure Surveillance
Clean water Immunization rates Electricity – cold chain Transportation Communication
Low Income Countries
Social and behavioral determinants
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
http://aidsinafrica1980s.wordpress.com Low Income Countries
Social and behavioral determinants
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
• Each Kilometer matters • Population-specific programs
Low Income Countries
Social and behavioral determinants
• Household living conditions
• Parental education
• Religious and minority groups
• Migration
• War and civil unrest
• Gender-based inequity
• Women’s role and power
• Urban vs Rural residence
• Program accessibility
• Traditional healers
Low Income Countries
Social and behavioral determinants
Determinants important for the success of Immunization programs
Biological
• Vaccine efficacy
• Vaccine safety
• Epidemiology
Non-biological
• Economy/Finance
• Politics/Government
• Social environment
• Logistics
√
√
√
What happens when a new vaccine is introduced?
Low-income countries
New Vaccines Low-income countries
Vaccine Disease to prevent
Hepatitis B Hepatitis / Liver cancer
Haemophilus influenza
type b
Meningitis
Epiglotitis
Pneumonia
Rotavirus Diarrhea
Streptococcus
pneumoniae
Pneumonia Meningitus
Neisseria meningitidis A Meningitis
Human Papilloma Virus Cervical Cancer
New Vaccines Low-income countries
Vaccine Disease to
prevent
Initial Year of
GAVI’s support
Hepatitis B Hepatitis/Liver
cancer
2000
Haemophilus influenza
type b
Meningitis
Epiglotitis
Pneumonia
2000
Rotavirus Diarrhea 2007
Streptococcus
pneumoniae
Pneumonia
Meningitus
2007
Neisseria meningitidis A Meningitis 2011
Human Papilloma Virus
Cervical
Cancer
2014
Models for Introduction of new vaccines into low-income countries
• Haemophilus type b vaccine
• Hepatitis B vaccine
• The first new vaccines introduced to low income countries
Group I
Hib and HepB
Group II
HepB
Group III
Neither
Benin Cameroon Angola
Burkina Faso Comoros Chad
Burundi Cote D’Ivoire CAR
Gambia Eritrea Congo
Ghana Lesotho Congo DR
Kenya Madagascar Ethiopia
Malawi Mauritania Guinea
Mali Mozambique Guinea-Bissau
Rwanda Nigeria Liberia
Senegal Tanzania Niger
Uganda Zimbabwe Sierra-Leone
Zambia Togo
New Vaccine Introduction GAVI-eligible African Nations
GAVI phase I (2000-2005)
New Vaccine Introduction GAVI-eligible African Nations
GAVI phase I (2000-2005)
Determinants evaluated
• Country population size
• Life expectancy - males
• life expectancy – females
• No. doctors/1,000 people
• No. nurses/ 1,000 people
• Financial indicators related to healthcare
• Country-level Governance Indicators
Determinants evaluated
• Country population size No difference
• Life expectancy – males No difference
• life expectancy – females No difference
• No. doctors/1,000 people No difference
• No. nurses/ 1,000 people No difference
• Financial indicators related to healthcare
• Country-level Governance Indicators
Determinants evaluated
• Healthcare financial indicators – GHECAP: Government healthcare expenditure per capita
– THECAP: Total healthcare expenditure per capita
– HEGDP: Total healthcare expenditure as % of GDP
• Governance indicators – Political stability
– Government effectiveness
– Rule of Law
– Quality control
– Control of corruption
– Voice and accountability
B
19951996
19971998
19992000
20012002
20032004
2005
pp
p i
nt.
$
20
40
60
80
100
A
19951996
19971998
19992000
20012002
20032004
2005
pp
p i
nt.
$
0
10
20
30
40
50
Group I (HibHep)
Group II (Hep)
Group III (None)
*
*** **
C
Year
19951996
19971998
19992000
20012002
20032004
2005
%
3
4
5
6
7
8
* *
Figure 1
Financial healthcare indicators
pre-GAVI and the first phase of GAVI's funding
GHECAP
THECAP
HEGDP
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802
E
Year1996
19982000
20022003
20042005
0
10
20
30
40
50
60
**
*
**
*
*
**
F
Year1996
19982000
20022003
20042005
0
10
20
30
40
50
60
* * ** ** ***
*
C
19961998
20002002
20032004
2005
Perc
en
tile
Ran
k
0
10
20
30
40
50
60
**
*
** **
* *
** **
* *
****
D
19961998
20002002
20032004
20050
10
20
30
40
50
60
**
*
**
*
** ** **
*
**
*
B
19961998
20002002
20032004
20050
10
20
30
40
50
60
**
** **
** **
**
**
*
**
**
* *
**
A
19961998
20002002
20032004
2005
Perc
en
tile
Ran
k
0
10
20
30
40
50
60
Group I (HibHep)
Group II (Hep)
Group III (None)
**
*
*
**
Perc
en
tile
Ran
k
Figure 2
Governance Indicators pre-GAVI and the first phase of GAVI's funding
A. Political stability
B. Government
effectiveness
C. Rule of law
D. Quality control
E. Control of
corruption
F. Voice and
accountability
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802
Year
1996 1998 2000 2002 2003 2004 2005
Per
cent
ile R
ank
0
10
20
30
40
50
60 Group I (HibHep)
Group II (Hep)
Group III (None)
*
*
**
* *
**
*
****
**
** **
**
Figure 3
Combined Governance Indicator Score
pre-GAVI and the first phase of GAVI's funding
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802
Governance Indicators
Healthcare Financial Indicators
QCA - Qualitative Comparative Analysis Pre-GAVI (1995-1999)
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802
Governance - better predictor than Finance for New vaccine introduction
Governance Indicators
Healthcare Financial Indicators
Non-biological Determinants Conclusion
• Social and behavioral environment
• Governance
• Finance
Important factors to be considered in the introduction / implementation of vaccination program
Governance
Finance
Social and behavioral environment
New vaccine introduction Non-biological determinants
Acknowledgments
• Katherine A. Nichols
• David W. Britt
• Victor G. Rodwin
• Mary-Louise Cohen
• Robert F. Porges
• Ivy Rayos Saludes
• Kevin Steffens
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