1. 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

2. Non-biological determinants
of
Immunization Programs

3. What will happen when a new vaccine for
TB is available ?
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Introduction
Public acceptance
Finance
Sustainability

4. Determinants important for the success of
Immunization programs
Biological
Non-biological
• Vaccine efficacy
• Vaccine safety
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• Epidemiology
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• Economy/Finance
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• Politics/Government
• Social environment
• Logistics

5. Determinants important for the success of
Immunization programs
Biological
Non-biological
• Vaccine efficacy
• Vaccine safety
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• Epidemiology
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• Economy/Finance
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• Politics/Government
• Social environment
• Logistics

7. Low Income
Countries
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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

8. Low Income Countries
Social and behavioral determinants
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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

9. • Childhood vaccines
• Basic vaccines
Polio, Diphtheria, Pertussis, Tetanus, Measles, BCG

10. Role of social environment
Low Income Countries
Availability of immunization services within a
walking distance did not always translate to their
usage

11. Low Income Countries
Social and behavioral determinants
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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

12. Low Income Countries
Social and behavioral determinants
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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
Access to higher
education

13. Low Income Countries
Social and behavioral determinants
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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

14. Low Income Countries
Social and behavioral determinants
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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
Electricity – cold chain
Transportation
Communication
Immunization rates

15. Low Income Countries
Social and behavioral determinants
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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
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16. Low Income Countries
Social and behavioral determinants
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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

17. Low Income Countries
Social and behavioral determinants
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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

18. Determinants important for the success of
Immunization programs
Biological
Non-biological
• Vaccine efficacy
• Vaccine safety
√
• Epidemiology
√
• Economy/Finance
√
• Politics/Government
• Social environment
• Logistics

19. What happens when a new vaccine
is introduced?
Low-income countries

20. 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

21. 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

23. 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

24. New Vaccine Introduction
GAVI-eligible African Nations
GAVI phase I (2000-2005)
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

25. New Vaccine Introduction
GAVI-eligible African Nations
GAVI phase I (2000-2005)

26. Determinants evaluated
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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

27. Determinants evaluated
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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

28. 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
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Political stability
Government effectiveness
Rule of Law
Quality control
Control of corruption
Voice and accountability

29. Financial healthcare indicators
pre-GAVI and the first phase of GAVI's funding
Figure 1
50
A
Group I (HibHep)
Group II (Hep)
GHECAP
ppp int. $
40
*
Group III (None)
**
**
*
30
20
10
0
5
6
7
8
9
0
1
2
3
4
5
199 199 199 199 199 200 200 200 200 200 200
100
80
ppp int. $
THECAP
B
60
40
20
5
6
7
8
9
0
1
2
3
4
5
199 199 199 199 199 200 200 200 200 200 200
8
C
*
7
6
%
HEGDP
*
5
4
3
5
6
7
8
9
0
1
2
3
4
5
199 199 199 199 199 200 200 200 200 200 200
Year
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802

30. Governance Indicators
pre-GAVI and the first phase of GAVI's funding
Figure 2
Group I (HibHep)
Group II (Hep)
Group III (None)
A. Political stability
B. Government
effectiveness
Percentile Rank
A
B
60
60
50
*
* *
40
50
30
30
20
20
10
10
* **
0
6
8
0
2
3
4
5
199 199 200 200 200 200 200
E. Control of
corruption
C
Percentile Rank
D. Quality control
D
60
60
50
** ** ** ** ** ** **
40
50
30
30
20
20
10
10
* * *
* *
0
Percentile Rank
*
* * *
0
6
8
0
2
3
4
5
199 199 200 200 200 200 200
6
8
0
2
3
4
5
199 199 200 200 200 200 200
F
60
60
50
** ** *
40
50
40
30
20
** ** *
** * *
30
20
10
0
* * *
*
6
8
0
2
3
4
5
199 199 200 200 200 200 200
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802
** ** ** ** ** **
40
E
F. Voice and
accountability
* ** ** ** ** * *
0
6
8
0
2
3
4
5
199 199 200 200 200 200 200
C. Rule of law
* * **
** ** ** **
40
Year
10
0
*
6
8
0
2
3
4
5
199 199 200 200 200 200 200
Year

31. Figure 3
Combined Governance Indicator Score
pre-GAVI and the first phase of GAVI's funding
60
Group I (HibHep)
Group II (Hep)
Group III (None)
Percentile Rank
50
40
*
**
**
**
**
**
**
**
*
*
*
*
*
2000
2002
2003
2004
2005
30
20
10
*
0
1996
1998
Year
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802

32. Healthcare
Financial
Indicators
Governance
Indicators

33. QCA - Qualitative Comparative Analysis
Pre-GAVI (1995-1999)
Glatman-Freedman A. et al. PLoS One 2010, 5 (11) e13802

34. Healthcare
Financial
Indicators
Governance
Indicators
Governance - better predictor than Finance for New vaccine introduction

35. Non-biological Determinants
Conclusion
• Social and behavioral environment
• Governance
• Finance
Important factors to be considered in the
introduction / implementation of vaccination
program

36. New vaccine introduction
Non-biological determinants
Governance
Finance
Social and behavioral
environment

37. Acknowledgments
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Katherine A. Nichols
David W. Britt
Victor G. Rodwin
Mary-Louise Cohen
Robert F. Porges
Ivy Rayos Saludes
Kevin Steffens