Institutional Mistrust and Child Vaccination Coverage in Africa

"Recognising the extent to which a lack of institutional trust jeopardises vaccination campaigns is crucial to improve immunisation rates."

While the persistence of subnational pockets of low vaccination coverage in Africa has been attributed to societal, cultural, and religious considerations, as well as to limited access to vaccination services and to caregiver knowledge gaps, researchers are increasingly pointing to the role of vaccine hesitancy in hindering progress towards universal child immunisation coverage. Qualitative evidence suggests that lack of trust in local and national authorities is linked to vaccine hesitancy and refusal across the continent. For example, lack of trust in governments has been found to lead parents to question the vaccine information they receive from health authorities and thus affect their decisions to vaccinate their children. This study sought to quantify the role of institutional mistrust on child vaccination uptake in 22 African countries.

The researchers matched information on child vaccination status from the Demographic Health Surveys (DHS) with information on institutional trust from the Afrobarometer surveys at the subnational level. A total of 166,953 children from 41 surveys administered in 22 African countries covering 216 subnational regions were used. Based on a principal component analysis, the researchers constructed an institutional mistrust index that combined the level of mistrust in the head of state, parliament, electoral system, courts, and local government. Associations between institutional mistrust and child vaccination uptake were assessed with multivariable fixed effects logistic regressions that controlled for time-invariant subnational region characteristics and various child, caregiver, household, and community characteristics. (The methodology is detailed in the paper itself and in supplementary materials.)

About 6% of the children aged 12-59 months in the sample had not received any of the eight basic vaccinations, while 62% had received all of them. Institutional mistrust at the subnational regional level was highest with respect to the electoral system (with 20% of the population indicating having "no trust at all"), followed by mistrust in local government (18%), parliament (17%), head of state (14%), and courts (14%). Compared with countries in Eastern Africa, institutional mistrust in public institutions was generally higher among countries in West Africa and Southern Africa. However, there were considerable subnational variations in levels of mistrust and vaccination coverage.

Multivariable fixed effects logistic regressions indicated that institutional mistrust was strongly associated with child vaccination status. A 1 standard deviation (SD) increase in the institutional mistrust index was associated with a 10% increase in the likelihood that the child had not received any of the basic vaccines (95% confidence interval (CI) of odds ratios (ORs): 1.03 to 1.18). Similarly, a 1 SD increase in the institutional mistrust index was associated with a 6% decrease in the likelihood that the child had received all basic vaccinations (95% CI: 0.92 to 0.97). Institutional mistrust was negatively associated with the likelihood that a child had received each of the eight basic vaccinations (p<0.05).

In short, this study found that increases in mistrust in public institutions were strongly and negatively correlated with child vaccination uptake, even after controlling for differences in a number of child, caregiver, household, and community characteristics, including access to and utilisation of healthcare services. The researchers also conducted a battery of sensitivity checks in order to confirm the findings.

Recommendations based on these findings include:

• Strengthen ongoing communication efforts on the benefits of vaccines that also address myths and misunderstandings.
• Build trust and confidence in those providing the information and delivering vaccination services by empowering local authorities, such as trusted political or religious leaders, with communication strategies to address mistrust.
• Cultivate a better understanding of the origins of mistrust in relation to vaccine hesitancy in order to guide specific policies in each country, in light of Africa's colonial past and in the history of slave trade.
• Conduct research to identify the mechanisms through which the determinants of vaccine hesitancy, such as the level of education, socioeconomic status, media exposure, and social norms, interact with public mistrust.
• Scrutinise the role of social networks, particularly in the context of COVID-19, where restricted mobility and physical isolation have provided online communities a new platform for spreading antivaccination views.

In conclusion: "Trust-smart policies are needed to protect the 2.6 million under-5 children estimated to be at risk of dying due to vaccine-preventable diseases by 2030..."