Mistrust in local and national government plays a significant role in slowing down child vaccination progress in Africa – the continent home to half of the world’s unvaccinated and under-vaccinated children, new research from Lancaster University Management School reveals.

A study published in BMJ Global Health finds child vaccination rates in African countries are considerably lower in areas where the local population has high levels of mistrust in local authorities. Even when comparing children from households with similar socio-economic characteristics, who live in the same area and have similar access to healthcare facilities, mistrust in local authorities, government, courts or the electoral system matters significantly when it comes to parents vaccinating their children.

Researchers from Lancaster University Management School, UCLouvain, the University of Antwerp and the International Food Policy Research Institute (IFPRI) studied information on the status of child vaccinations for close to 167,000 children across 22 African countries, and matched it with information on the levels of trust people had in local and national authorities.

Child vaccinations were significantly lower in regions where people did not trust the courts, parliament, the head of state and local government. For instance, when mistrust in local government increased by 10 percentage points, children living in that region were 11% more likely not to receive any of the eight basic vaccines (the BCG or Bacillus Calmette–Guérin vaccine, three doses of the combined diphtheria, pertussis, and tetanus vaccine; three doses of the polio vaccine, and a dose of measles-containing vaccine) and 3.4% less likely to receive all eight of the basic vaccines.

“Vaccine hesitancy was already recognised as one of the most important threats to global health before the Covid-19 outbreak, but was mainly documented in high-income countries like France or the US,” said co-author Dr Jean-Francois Maystadt, Associate Professor in Economics at Lancaster University Management School and UCLouvain. “Our quantitative analysis demonstrates that institutional mistrust is an important barrier in reaching universal child immunisation in Africa and poses a significant risk to vaccination campaigns – which are more important now than ever.”

Co-author Dr Nik Stoop, from the University of Antwerp, said: “Our findings back evidence from qualitative case studies across Africa, suggesting that mistrust is an important contributor to vaccine hesitancy. A well-known example of the impact of mistrust is the way Nigerian communities boycotted the polio vaccination in the early 2000s, leading to the outbreak of a disease that had almost been eradicated. But other examples can be found in many African countries, including from Cameroon, Chad, DRC, to Mozambique, Nigeria or South Sudan.”

Authors say while their study is the first comprehensive attempt to quantify the role of institutional mistrust on child vaccination uptake in Africa, the issue is not felt in the continent alone. Mistrust in authorities impacting on vaccine take up has already been documented in high-income countries like Russia, the US, France and Croatia, so researchers suggest these new findings should be of use to authorities around the world.

Based on their results, researchers argue there is an urgent need to recognise the importance of mistrust in vaccination campaigns, especially in a post-COVID world where the global roll-out of vaccines is considered crucial in bringing the pandemic to an end.

“There is no doubt that Covid-19 vaccination in Africa is limited by supply constraints and huge logistical challenges. But even if global allocation mechanisms like COVAX or the availability of new vaccines were to overcome these challenges, we would still need to convince people to get vaccinated,” continues Dr Maystadt. “The lack of action leaves room for anti-vaxxers, in a context where traditional medicine has already been unduly advanced in several African countries – presenting serious health risks to individuals and the continent as a whole.”

With the pandemic leading to the cancellation of several immunization campaigns, the authors call for ‘trust-smart’ policies in order to protect the 2.6 million under-5s who are estimated to be at risk of dying due to vaccine-preventable diseases by 2030.

They say that while strengthened myth-busting and communication around the benefits of vaccines is important, it is unlikely to be sufficient without trust and confidence in information providers improving significantly.

“Lessons from successful campaigns in Africa highlight the importance of engaging with local communities, trusted political or religious leaders and providing space for open dialogue. A top-down approach is unlikely to work,” adds Dr Kalle Hirvonen, co-author and Senior Research Fellow at the IFPRI. “However, a lot of uncertainties remain on how grassroots initiatives can be scaled up, and questions need to be asked about the role of social media within local communities. In a post-COVID world where mobility is curbed and people are more isolated, we’ve seen social networks become ideal platforms for spreading anti-vaccination views.”

The paper, “Institutional mistrust and child vaccination coverage in Africa”, is published in the BMJ Global Health today.

DOI:10.1136/bmjgh-2020-004595