critical academic writing demonstrating your understanding and critical evaluation of key public health topic and its relationship to policy and practice essay

TOPIC:
Immunization/Vaccination Programs in Prevention of Measles in the United Kingdom and other Developing Countries.Introduction
Public Health is referred to as the science of protecting and improving the health of people and communities which is achieved by promoting healthy lifestyles along with detection and prevention of infectious diseases in a group of people as small as a community or as large as a country or a region of the world (CDC, 2019); and this encompasses assessing and monitoring the health of communities, creating public policies to enable local and national issues to be solved ensuring communities can access cost effective healthcare for prevention of disease and promotion of health (Shiel, 2019).
Measles is a public health issue of global concernas a single case can project into an outbreak (Gastanaduy et al., 2018); this is because public health is intertwined with population health which refers to health outcome of a group of individuals or a community (Kingdig and Stoddart, 2003). This is supported by Arah (2008), who agrees that population health is created as a dichotomy of public health.According to WHO (2019), there is about 11,0000 measles death among children under five and availability of the measles vaccine in 2017 resulted in 80% drop in measles death globally. Measles is mostly common in developing countries especially in Africa and Asia (WHO, 2018). CDC (2019), reported about 750,000 deaths in developing countries in the year 2000.Hopkins et al., (1982), assert that more deaths from measles infection are seen in low income per capita countries with weak health infrastructure. However, this could be prevented with the Measles, Mumps and Rubella (MMR) vaccine which is 93% effective at a single dose and 97% effective at two doses (CDC, 2019).The MMR vaccine was introduced in 1988 to safeguard against the spread of measles, two doses of the MMR vaccine is required for effectiveness (NHS, 2018).
Measles is a contagious viral disease that affect children, infants and persons with weakened immune system; some of the symptoms include fever, running nose, cough, skin rashes and watery eyes (Brennann, 2019).The measles virus belongs in thefamily of Morbilliviruses which share similar characteristics with the rinderpest virus a pathogen of cattleas a result referred to a zoonotic infection (Furuse, Suzuki and Oshitani, 2010; Mosi,2017). Measles infectionoccurs in late winter and early spring in temperate climate countries and after the rainy season in tropical countries (Guerrant, Walker and Weller, 2011). The transmission of measles is rapid, occurring in approximately fifteen minutes of being in contact with an infected person, outbreaks can therefore occur unexpectedly(NHS, 2017). Under-nourished children experience the severe form of measles due to deficiency of vitamin A(WHO, 2019), and some of these severe complications include blindness, severe diarrhoea and encephalitis(WHO, 2019). A study by Trentini et al. (2017), using a transmission model on serological data shows that susceptibility to measles in the United Kingdom (UK) varied at 3% compared to Ethiopia at 12.5%,although occasional episodes of outbreaks are recorded in European areas and even America where elimination was achieved in 2016.Thus, this essay will critical explore the vaccination program in primary care used in the prevention of measles, identifying some of the social determinants that influence an effective vaccination program and how it has been addressed to achieve a better public health outcome in the United Kingdom (UK) and developing countries.Vaccination in National, Cultural and Global Public Health Context
The World Health Organization (WHO) started the Expanded Programme on Immunization(EPI)in 1977 to ensure universal immunization for children by 1990 (WHO, 2013); this has remained an essential tool in managing and restraining the spread of measles resulting to the declaration of the 21st century as a preventive era. In both developing and developed countries the aim of measles immunization has remained same to achieve high immunization coverage with two doses of the vaccine (Cutts et al., 1991). Nevertheless, developing countries still experience low measles immunisation coverage due to inaccessible and nomad populace, and also poor storage of vaccines leading to vaccine failure (Cutts and Dabis, 1994). According to Riumallo-Herl et al. (2018), vaccination programs in low income countries requires financial capital policy outcome to tackle most of the factors affecting effective immunization programs.
Although immunization has been recorded to be successful in certain developed countries, some of these countries still struggle with complete immunization coverage(Cutts et al., 1991; Riumallo-Herl et al., 2018).In the United Kingdom (UK), a study conducted by Dr Wakefield that showed a correlation between MMRvaccine and autism has been discredited (NHS, 2018). However, studies have shown that this claim was linked to the reduction in vaccination of children leading to further outbreak of measles;hence, the loss of measles free status in the UK (Kennedy, 2019).
In relation to culture, vaccination programs have been perceived from different perspective by different countries. In developed countries religious beliefs such as unorthodox Jews or the people of high socioeconomic class believes that immunization is imposed on them by the government, adding thatpharmaceutical companies produce unreliable vaccine which further contributes to the challenges faced in curtailing measles (Kahn, 2016). Cultural beliefs and values play an integral role in the success of vaccination programs as cultural perspectives emanate from controversies in individual rights and compulsory vaccination. For example in the United States where vaccination has been made compulsory for all children entering school but this has posed a challenge for children from low income families or children without health insurance being unable to access vaccination (CDC, 2017).
According to Jones, Sciamana and Lehman (2010), studies on the use of complementary and alternative medicine (CAM) reveals that parents who believe in CAM will less likely adopt immunization procedures or will likely believe more in the myths of vaccination not being appropriate for children. Also, Salmon et al. (2004) agrees with the study showing school correspondences who believed in CAM and worked with parents concerning immunization were less likely to support the use of vaccines. This aspect of cultural diversity can barely be ignored when proposing the use of vaccination programs in prevention of measles.
In developing countries such as Africa, cultural perspective on vaccination could stem from beliefs of immunization strengthening children and indirectly making them more violent, this causes a much wider social and political challenge to the success of vaccination programs (WHO, 2008). The Global perspective on vaccination has viewed vaccination as one of the successes of public health in abating mortality and morbidity, although various challenges have been encountered as seen in vaccine hesitancy which defines a group of people ranging from defectors and those entirely refusing vaccines (Larson et al.,2014).Current and Past Policies on Vaccination
The Global vaccine plan was recommended to eradicate measles in four WHO regions in 2015 and by 2017 this resulted in 80% reduction in death (WHO, 2019). This led to the introduction and development of the MMR vaccine which is known to be safe and effective (CDC, 2019). In year 2000, the United States was able to eliminate measles using the MMR vaccine and assisted in the strengthening vaccination in public health to influence a healthy outcome (Munro and Savel, 2015). The Global Advisory Committee on vaccine safety was inaugurated in 1999 to address the WHO safety issues concerning vaccines and to prompt efficient and scientific response especially on the global importance (Folb et al., 2004).
Current policy in the UK is the use of two doses of MMR vaccine especially in children below 5years of age as well as catch-up being achieved on older children or young adults who missed out on immunization (PHE, 2019).In 1996, the 2nd dose was introduced to boost the initial dose and maximise the desired output (PHE, 2018). The UK had its first 50 years of introducing the measles vaccine in 2018. The MMR capital catch-up was inaugurated in 2004 as there was a markedly increase susceptibility of children following a decrease in MMR coverage and finally in 2016 the UK obtained a measles elimination status from WHO (PHE, 2018).
Currently importation of measles virus in the UK has been identified from migrants of other European countries due to low uptake of the MMR vaccine in those countries therefore the consequential effect is to administer and maintain high coverage of the doses as this will enable herd immunity (PHE, 2019).Social determinants of non-utilization of measlesvaccination.
Social determinants of healtharerequired in analysing and assessing public health policies. Impoverished social and economic situation can cause a poor effect on health outcome (Marmot and Wilkinson, 2005). Social determinant of health is important to ascertain factors which may affect healthy outcomes in communities. In 2004, the WHOclearly stated the need for considering the role social determinants of health play in the overall expected health outcome especially in vulnerable populations such as women, children and minority groups (WHO, 2018). Social determinants of health are conditions people are born, develop, work and age while these conditions can be pre-determined by resources at global, national or local levels (WHO, 2019). The Marmot Review of 2010 focuses on the need to reduce social determinants to curtail health inequalities within and between countries (Marmot et al.,2010).
Different models have been used in discussing social determinants of health such as the Dahlgren & Whitehead model to explain how socio-economic factors influences health status (PHE, 2017). According to Dahlgren and Whitehead (1991), social determinants show that level of health outcome can be associated with socio-economic factors and in addressing these factors such as economic, environmental and social inequalities, the reduced risk of illnesses and accessing healthcare will be optimized. Although other models have been developed and adopted such as the Evans and Stoddart (1990), the Dahlgren and Whitehead model was adopted as an inquiry into health inequalities in the United Kingdom (Whitehead and Dahlgren, 1991). Some social determinants have been identified to influence immunisation coverage across countries based on income level and various other factors (Glatman-Freedman and Nichols, 2012). However, there are notable differences in social determinants between developing and developed countries.
Household living conditions: This affects areas which are referred to as slums where access to healthcare services are constrained. Vaccination programs may not be accessible due to low income per household affecting transportation to clinics. Slums generally can increase spread of infectious disease when herd immunity is not achieved increasing mortality rates (Cutts, 1991). This may not occur in developed countries or high-income communities as income per household may be affordable. Unemployment may also contribute to low income per household.
Education: Maternal education regarding immunization has been found to play a role in percentage of children immunized (Kusuma, 2010). According to Forshaw et al. (2017) a higher education status among men and women results in less prejudice against use of vaccines and increases vaccination uptake. Though,Nichter (1995) stated that there was no apparent affiliation between the educational knowledge of parents and the coverage rates of vaccination. However, Rammohan et al. (2012) studies postulated that paternal education influence in six nations independent of maternal education after all confounding variables were restrained was significant for the measles vaccination uptake in children. In Pakistan, followers of the AgaKhan are predominantly illiterate but were culturally receptive to vaccination and its benefits (Jheeta, 2008).
Social and Community Networks: Communities where cultural beliefs and values influence decisions to vaccinate positively usually tends to loss of herd immunity. Eames (2009) agrees to this by explaining interaction between these children and other children are generally inevitable thus spreading the infectious disease. Cultural perspective affects vaccination uptake differently amongst certain population. Glatman-Freedman and Nichols (2012) stated immunization rates of 66% among Christians’ as against 32% among Muslims in Nigeria. Gyimah (2007) explains that cultural influences in communities could be due to marginalisation from neighbouring societies, honouring opinions of religious leaders and non-accessibility to health or social programs. The use of complementary and alternative medicine (CAM) has become quite known over the years as well as beliefs that vaccination is more detrimental than beneficial (Ernst, 2001). Therefore putting communities which practice CAM at risk of lower vaccination coverage.
Demographic attributes: Biological factors such as age and sex has quite less documented evidence to its effect on vaccination however a study in India shows that gender inequities are prevalent where boys are likely to be immunized than girls which could lead to risk of child mortality for the girl child (Corsi et al.,2009).
Technology: Communication can be used in educating the public about vaccination and abolishing misconceptions about vaccines. Mobile based technology can be used as evidence-based modifications to deliver immunisation messages and healthcare service. For example in a developing country like Kenya a study showed the effectiveness of house to house visits using mobile technology (Mbabazi et al.,2014). However in the UK technology has shown an era where social media technology has created a misconception about the perceived negative risk of vaccination resulting in a lower vaccination coverage (Campbell, 2019).
Environment: In developing countries environmental factors such as clean water, sanitation and power supply to ensure cold chain delivery can contribute to low vaccine uptake. Glatman-Freedman and Nichols (2012) also stated how civil unrest and wars affect the environment causing disruption to transportation of cold chain vaccines to communities. In developed countries bad weather can sometimes be a barrier to transportation to clinics especially during periods of keen vaccination campaigns.Public Health Ideologies that influences Vaccination.
Social determinants generally pose a problem for policymakers in public health; this is because health inequalities are a major issue in better health outcome (Exworthy, Blane and Marmot, 2003). Policies and ideologies are usually implemented especially in the UK;although, Hunter et al. (2010) observed that public health struggles with its influence over policies due to its lack of identification distinctiveness. This led to efforts to widen the responsibilities of public health. Hunter and Mark (2005) explained this to involve governments and other relevant organizations which were promoted under public health governance.
Paternalism Ideology:The paternalism perspective is the state of intervening on an individual without giving them choices in protecting them from ill health (Dworkin, 2005). This view was based on inequality in power, status and authority and is usually referred to as the nanny state relating to unnecessary interference in peoples’ freedom (Dworkin, 2005). However, Gostin (2007) argued that in cases where an individuals’ choice could deeply affect the society such impediment on freedom could be well justified. Although paternalistic approach may work in vaccination in addressing the benefit for the greater good but other studies such as Macintyre (1992) suggested that paternalistic views in empirical terms does not show that people with restricted autonomy have better health or in the case of immunisation may suffer poorer infectious disease state.
Liberalist/Individualist perspective: Thisis considered influential in the UK (Baggot, 2000). Individuals are granted the freedom to make choices by themselves not promoting the nanny state.According to Baggot (2000), in relation to vaccination, research has shown that operating the liberalism perspective poses a problem that affect the success of immunisation program.Dube et al. (2013), supported this view and suggested that individual choices create problem of vaccine hesitancy and loss of herd immunity.
Collectivist and Socialism: Considers that interventions are not only to protect individuals but to promote health of everyone regardless of position in the society (Baggot, 2000). As observed by Jochelson (2006), government intervention in public health should be considered that of stewardship and set regulations for the benefit of the public. Vaccination programs can therefore aim to convince parents why immunisation is important by showing the risk associated rather than use of coercion.
Another ideology relevant to vaccination is the Green Ideology which stems from the perspective that illnesses emanate from the use of the environment by man, it promotes more of an ecological standard of health (Baggot, 2000; Draper, 1991). This ideology will support a healthy environment as a social determinant of health. Some parents believe vaccines should be made with organic products for it to be safe however this myth has been debunked about the MMR vaccine where further studies have shown its ingredient are not harmful (Jakobsen,2015). The green ideology promotes the use of vaccine as a safe and effective method of preventing ill health.
Different countries adopt different ideologies while some use the collectivist perspective to encourage immunisation, some countries use the liberalism approach and risk loss of herd immunity. Other countries such as United States and Australia utilise weakened paternalistic approach where sanctions such as non-registration into school and no jab no pay policies are respectively used (Scutti, 2018).How the U.K Government addresses Immunisation as a Public Health Issue
UK is reported to be foremost in vaccination, uptake of vaccines has slowly declined from 2012 to 2013, which was evident in the loss of the measles elimination status in 2016 (Kassianos and Ramsay, 2019). However, certain measures in terms of health protection, health improvement and healthcare services have been implemented. Public health practice of vaccination is classified under three major practices of health improvement, health service delivery and health protection (Baggot, 2000).
The United Kingdom developed different teams such as NHS England screening and immunisation, Public health England protection, travel and occupational health etc. to ensure continual and proper communication with the public on immunisation and prevention of infectious disease (NHS, 2019). The U.K strategy in managing outbreak was in propagating further outbreaks and tackling the age bracket which are susceptible to measles, this was done by utilizing the catch-up campaign (NHS, 2013). However the challenge still remained of children in disadvantaged areas that has a higher percentage of susceptibility (Keenan et al., 2019).
Health improvement:In health improvement, the UK aimed to promote healthy choices by formulating healthy programs to educate the public on choices they make. Public health England constituted the Healthy child program in 2019 to promote health, surveillance, screening and immunisation (Webb and Sheriff, 2016). Another strategy is the Healthy Start Program which aims to improve the health of low income pregnant women and families on benefit and tax credit by providing vouchers and vitamins (PHE, 2019). This was done to reduce poverty levels which could affect immunisation status in these families. Other factors such as transportation, communication and learning disability are addressed by offering longer appointment times, walk in immunisation clinics, extended hours for services, service through mobile outreach (PHE, 2019).
Healthcare service:Healthcare service issues are addressed by ensuring that healthcare practitioners are properly trained on the delivery of immunisation services. The UK government addresses this in the school-age immunisation team comprising of registered nurses and healthcare support workers. The programme takes place in schools, community clinics or homes for children who are unable to access the service in school (NHS, 2019). Healthcare services also use the method of sending invitations or reminder and evidence has shown that calls or recalls is an effective intervention tool in upscaling vaccine uptake (Kassianos and Ramsay, 2019). Healthcare workers are also updated about vaccines to enable them speak confidently and answer queries which parents may ask concerning vaccination.
Health protection:Health Protection theories on protective behaviours used to analyse peoples’ behaviour in immunization include Theory of reasoned action, Triandis model, Multi-Attribute Utility theory and the Health Belief Model theory (Bond and Nolan, 2011). The Health Belief Model is widely utilized and comprises of perceived susceptibility, perceived severity, perceived benefits and perceived barriers (Glanz et al., 2008). Although other studies have shown contradictory findings regarding the relevance of the Health belief model to immunisation uptake (Zimmerman, 1996); Bates (1994) agrees by stating poverty and education as socio-economic factors have more important influences on immunisation than a health belief model to effect behavioural changes.
The theories of health protective behaviours may have shown behaviours in non-compliant and compliant people towards immunisation; however, it fails to explain how the risk is perceived and how this perception may influence behaviour towards vaccination (Bond and Nolan, 2011). Nelkin (1989),argued that there exist no particular association between morbidity or mortality rate and the perception of risk specific to vaccination.Health Economics and Evaluation of Measles Vaccination
In North East England, measles outbreak was reported in 2012 while in Merseyside area the largest measles outbreak occurred between 2012 and 2013 despite good vaccination uptake (Wise, 2013). Economic cost to public health in an outbreak may include tracing of contacts, control of infection especially in isolation sites, healthcare staff exclusions, immunity status screening, local ambulance services, cost to employer for absence due to the outbreak (Keenan et al., 2016). Cost of treatment or the cost of constraint is usually considered but not total cost of the community outbreak (Carabin et al., 2002).
Prevention of the outbreak was calculated based on the assumption that, to achieve herd immunity means 95% of children must receive two doses of the MMR vaccine. The cost of the outbreak relative to the cost of prevention in Merseyside in 2012 includes extra 11,793 vaccination over five years(NIHR, 2016). Total cost of outbreak was £4.4 million excluding sensitivity analysis which comprises of 15% of NHS treatment cost and extra cost for achieving herd immunity was £182,909 only 4% of total cost of a measles outbreak (NIHR, 2016). Striving to achieve a 95% vaccine uptake using the Merseyside experience gives a greater value of economic resources than risking an outbreak.
In 2013, in England there were confirmed cases of measles in children between the ages of 10-16 years which led to the launching of the National MMR catch-up campaign by General Practitioners (GP), National Health Service and Public Health England (PHE, 2014). Data was collected from local child health information systems (CHIS). The effectiveness of the GP based catch-up campaign was evaluated specially to ascertain if a national school based catch-up campaign was required. This evaluation was done based on the objectives of 10-16 year olds who were vaccinated before the campaign started, number of this age group who had received at least one dose of the MMR and the number in this age group who had not been vaccinated. A study by Simone et al (2014), showed that there was need to ensure records of previous vaccinations are maintained and not lost in children of the 10-16 age group. They further suggested that further campaigns were not necessary as 95% coverage was estimated to be achieved through the catch-up campaign.The evaluation study identified other factors related with non-vaccination should be further studied (Simone et al., 2014).Conclusion
Vaccination Programs in Primary Care has been of challenge in both developing and developed countries especially in the area of measles. In early 2019, measles cases were still reported in countries such as Democratic Republic of Congo, Ethiopia, Madagascar, United States and Sudan; however, it is preventable at 95% vaccination uptake, global coverage is still at 85% at first dose (WHO, 2019). Programs such as Measles and Rubella Initiative, Gavi, the Vaccine Alliance and United Nations International Childrens’Emergency Fund are operations developed to reduce outbreaks in countries, booster vaccine uptake coverage and enhance healthcare services (CDC, 2019). WHO (2019), data shows that more measles cases are still reported globally than any previous years since 2006 showing figures of 182 countries reporting 364,808 cases of measles.
In the UK, the elimination status was gained in 2017 but subsequently lost as there was considerable increase in confirmed measles cases in 2018. As long as measles remains a global issue there will be the likelihood of importation of cases into the UK. To limit this a 95% herd immunity should be achieved by maintaining coverage with two doses of MMR vaccine and catch up program targeting older children who missed earlier vaccination (PHE, 2019). According to PHE (2019), a measure of the public confidence in the UK vaccine program is excellently soaring,although this seems to contrast with the findings of 231 confirmed cases of measles in the first quarter of 2019. A proposed course of action could include action on General Practitioners (GP) to promote catch-up campaigns and social media to demerit news concerning anti-vaccines (BBC, 2019).
The implications of this essay is to propose best practices that can be adopted in GP clinics to identify children who are not vaccinated. This could be achieved through invitation letters and ensuring first doses of the vaccine are achieved at first year of life. Suggestion for further research into adopting policies which will include school policies where children must be vaccinated before commencing school at age four; This policy is being utilised in the United States, where children cannot commence school year without proof of vaccination (Seither et al., 2019). In contrast Ferguson (2019) suggested that this process could prove disadvantageous in the United Kingdom as people may likely react to being forced to engage in vaccine uptake.Personal Reflection
During this module my communication skills of listening, speaking and work representation was heightened during my interaction with my tutors and classmates. The seminar work involved our discussion of a topic which was taught in the morning session. It has been of good interest to me while discussing from different ethnic perspectives and professional experiences how different public health issues occur globally and can differ in different countries and context. The formal presentation has marked up my skill in speaking up especially in a room full of people. Good insight was gained during this module about public health issues from several dimensions and perspective. This module perked my interest and flair for how public health intervention works in analysing public health issues. It was also interesting to note how different people view public health issues in its context.References:
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