Vaccine uptake is influenced by many complex socio-political processes, not just knowledge about them, something which qualitative research has revealed.
Conducting qualitative research takes time and effort, but it interrogates essential contexts and meanings that shape our health and healthcare
Public health challenges are never simple, particularly in a country as socio-politically diverse as South Africa. While scientific and quantitative research provides invaluable evidence to shape interventions, there’s a crucial missing link in many health programmes — qualitative research. This often-overlooked method holds transformative potential for South Africa’s public health efforts, particularly in understanding and addressing vaccine hesitancy.
Qualitative research explores individuals and contexts within their natural settings to acquire a comprehensive understanding of social phenomena. By analysing power structures and relations, qualitative evidence can uncover the roots to many health problems that lie within social systems and institutions. Further, by turning its focus to the individuals within these structures, it can investigate how actors within particular contexts experience different interventions or phenomena. It takes the perspectives of those actors into account, providing them with agency. It can unsettle widely-held assumptions about the actions of people, which may generate insights into the complex factors that facilitate, or hinder, the success of a health intervention in real-world settings. This takes us from beyond questions as to whether an intervention works or not, to why and how the processes emerge in terms of contexts and meanings that shape health and healthcare.
Our recent work within our critical social and behavioural sciences (SBS) programme of work demonstrates the valuable contribution of qualitative evidence within the area of vaccine hesitancy. We conducted three recent Cochrane systematic reviews synthesising qualitative research evidence on the nature and drivers of vaccine hesitancy for three different vaccines: routine childhood vaccines, human papillomavirus (HPV) vaccines for adolescents and the COVID-19 vaccine.
A central public health assumption about vaccine hesitancy is that it is driven primarily by a lack of information, and therefore, if people are provided with knowledge about the benefits and value of vaccines, uptake will increase. Yet our reviews demonstrated that uptake of vaccines is influenced by many complex socio-political processes and meanings, unrelated to knowledge about them. People’s vaccination views and practices were found to be shaped
- by social norms surrounding health and illness, childhood and parenting, sexuality and gender;
- by the relationships people have with institutions, systems and authorities;
- by growing disillusionment with science;
- by poverty and social exclusion; and,
- by geopolitical relations of inequality and oppression, to name a few.
We also found that knowledge and acceptance of vaccines interact in complex and often unexpected ways. For example, many parents who are hesitant about routine childhood vaccines had a very sophisticated understanding of vaccines, including their composition, functioning and potential risks; and ironically, a lack of biomedical knowledge about vaccines was found actually to enhance many parents’ acceptance of them.
Among others, this qualitative evidence suggests that we, as a public health community, need to add other dimensions to strategies of education and awareness-raising when people do not take up biomedical interventions. More multifaceted and complex strategies are imperative if our interventions are to succeed. For example, we used these findings to raise questions about the goals of public health interventions. We suggested that what should be at their core is building science literacy so people can make informed, consensual decisions about issues affecting their health and that of their community in general, and vaccination in particular. This will, in turn, contribute to improving the relevance, acceptability and ultimately the effectiveness of health policy and programmes.
We acknowledge that there are challenges. Economies of scale in government, in decision-making by policymakers and in assessments by donor agencies demand definitive and generalisable strategies that are based on standardised methods and quantifiable outcomes. When qualitative research is sought, it is typically reduced to simplistic or one-dimensional concepts such as “uptake”, “acceptability” or “feasibility”. Equally problematic is recourse to “quick and dirty” qualitative methods in the name of having included qualitative research, entailing the conduct of some interviews or focus groups.
The reality is that meaningful qualitative research takes time, developing theory and conceptual tools, which are available to the field more broadly; it involves reading widely, deeply, comparatively, and critically in the conviction that knowledge is cumulative; it entails ongoing engagement with communities in an attempt to understand their needs, priorities and realities; and it provides insights into what are often messy dynamics and diverse contexts, which are difficult to unravel. These do not easily translate into standardised outcomes, nor reproducible and “quick fix” interventions.
In the context of research funding priorities, we make a case for qualitative research to no longer be relegated to the sidelines. Ignoring this kind of research is at our peril, given the enormous public health issues facing South Africa today.
Dr Sara Cooper and Professor Mark E Engel work for Cochrane South Africa at the South African Medical Research Council. Cochrane SA has become an essential force in the advancement of evidence-based healthcare, playing a pivotal role in producing, promoting and translating high-quality research to improve public health outcomes, particularly in low- and middle-income countries.