Aharona glatman freedman social determinants sept 4-5 2013 -

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