The Vaccine Trust - Pakistan - Survey Results by ReD Associates

Trust Learnings: Building trust and changing behaviors

Read more: www.thevaccinetrustproject.com

The trust narrative Agenda

Introduction Trust and the effect on vaccine uptake Trust and the effect on vulnerable groups Appendix

Trust is one of these terms that everyone has an intuition about, and that we expect to matter for our interactions with each other —but at the same time, it has remained elusive and untapped in most situations. This study aims to change that. 3

I N T R O D U C T I O N

Prioritizing vaccine supply alone, falls short when we for example want to eliminate zero dose children, effectively contain a virus, or erradicate a disease—building trust seems a vital addition Reach keeps being an issue across vaccine campaigns and routine immunization…

C19

Polio

DTP3

AMBITION

STATUS

Global containment

17.7 million excess deaths and global, uncontrolled chains of infection1

Disease eradication

Reach all children

Repeating outbreaks in Nigeria and Pakistan2 14.3 million zero dose children by 20224

1) The Lancet COVID-19 Commission, 2022. “The Lancet Commission on lessons for the future from the COVID-19 pandemic.” https://www.thelancet.com/commissions/covid19 2) WHO, 2023. “Statement of the Thirty-sixth Meeting of the Polio IHR Emergency Committee”. https://www.who.int/news/item/25-08-2023-statement-of-the-thirty-sixth-meeting-of-the-polio-ihr-emergency-committee

One understudied phenomenon is the role of trust in health seeking behaviors

QUA LI TAT IV E

INSIGHT

During COVID19, we observed empty immunization wards despite solid local vaccine supply, illustrating how vaccine supply alone may fall short Empty “immunization” ward at a Kwara hospital, Nigeria. Summer of 2021

3) Gavi’s operationalized definition of zero-dose children: Children who don’t receive the first diphtheria-tetanus-pertussis vaccine. 4) WHO & UNICEF, 2023. “Progress and challenges with achieving universal immunization coverage”. https://cdn.who.int/media/docs/default-source/immunization/wuenic-progress-and-challenges.pdf

High trust drives vaccine uptake

MAIN FINDING

When trust increases, so does the likelihood of vaccination—we call this the trust dividend

High average trust score: 80

Current trust score KE: 71

95% of people would have been COVID-19 vaccinated in

Pakistan if the average trust score had been 80 – a trust dividend of 11%-points compared to the observed 84% vaccine rate

73% of girls would have been HPV vaccinated in Kenya if the average trust score had been 80—a trust dividend of 10%-points compared to the observed 63% vaccine rate

K E N YA

Level of trust

The trust dividend

Had trust scores been 80/100, vaccination rates would have been app. 10%-points higher in both Pakistan and Kenya PAK I STAN

Current trust score PK: 65

Plot: General trust’s effect on predicted likelihood of vaccination for HPV, COVID19, and childhood vaccines

Predicted probability of vaccination

The study shows:

*) Childhood vaccination rates are higher from the onset due to childhood vaccines' long history within maternal and pediatric healthcare and the nature of the data sample that skews towards higher childhood vaccination rates . 5

I N T R O D U C T I O N

This work addresses core challenges with existing approaches to trust—offering a new perspective to understand and work with trust in healthcare settings… S OLVI N G F OR . . .

Lack of agreement on what trust is

Situational and imprecise trust measures

Western-centric trust measures

Lack of decision-making involvement

There is disagreement within the quantitative trust literature on what trust is, which dimensions are important, and how to measure them

Existing trust measures are developed in an ad hoc manner and are rarely grounded in a deep, contextual understanding of trust

Existing trust measures are developed and validated in a Western context with insufficient attention to potential LMIC specificities

Existing trust measures devote little attention to solutions and decisionmakers’ perspectives and are rarely applied outside of academia

W H AT W E H AV E D O N E …

Operationalized and built on validated understandings of trust

Grounded in a deep, contextual understanding of trust

* For a more comprehensive outline on how the trust work solves existing challenges, see Appendix 1.

Build and validated in LMIC contexts with a focus on LMIC specificities

Developed in close conversation with decision-makers

I N T R O D U C T I O N

…and have resulted in a dataset that offers insight into previously understudied populations, shedding increased light on an array of vaccine behaviors and trust patterns W H AT W E H AV E D O N E …

W H AT O T H E R S H AV E D O N E …

Populations  

Male caregivers to adolescents Female caregivers to adolescents

Vaccine behaviors     

COVID-19 vaccine status HPV vaccine status Childhood vaccine status Zero dose status HPV vaccine awareness

Trust patterns      

Trust in the health system promise Trust in the healthcare delivery Trust in vaccine promises Trust in vaccine delivery Interpersonal trust Institutional trust

FinAccess Household survey

 Female caregiver  Male caregivers × No trust data × No vaccine data Kenya 2021 & Pakistan 2018 (Wave 7)

Kenya 2021

The Social & Living Standards Measurement Survey Pakistan 2018

Kenya 2021 & Pakistan 2018

× Only childhood vaccine status children under 5yo × No HPV vaccine status × No HPV awareness × No trust data

× Only childhood vaccine status children under 3yr × No link between household data & vaccine data × No trust data

Global Monitor: Kenya 2018 & Pakistan 2018

Kenya 2022 (Round 8)

 Institutional trust & interpersonal trust  Trust in healthcare system × No vaccine data

 Institutional trust & interpersonal trust  Trust in healthcare system × No caregiver data × No vaccine data

 Institutional trust & interpersonal trust  Trust in healthcare system × No caregiver data × No vaccine data 7

I N T R O D U C T I O N

In Kenya, our randomized sample of caregivers of adolescents skews towards higher incomes compared to general population benchmarks K E N YA

Income 10 000 KES/month 22%

Thousand KES 12%

• 26% of sample below national poverty lines: Despite the apparent skew toward higher income, our sample does represent low-income caregivers using the Kenya Bureau of Statistic’s poverty lines for urban and rural areas2

>25

5% 15-25

6-8

4-6

8-10

2-4

0-2

22%

17%

10-15

Median

We have reason to believe that this relative skew toward higher incomes represents our population of caregivers

*) See appendix for sampling strategy + full sample composition

Income In 2021, the median income for parents (of children of all ages) was 5.000 KES/month (FinAccess) 1

1) FinAccess, 2021: “FinAccess 2021”. Median income calculated based on full dataset, see https://finaccess.knbs.or.ke/reports-and-datasets

• Our sample ended up oversampling urban, and in turn, richer populations. Our sample design ended up oversampling urban populations who generally have higher incomes.3 • Our sample population is likely to be professionally active. Parents to adolescents are often in the most productive age (mid twenties to late forties) (see appendix), and, therefore, more likely to be part of the workforce than other population groups. • The most recent benchmark contains data from mid-C19-pandemic when poverty in Kenya peaked, suggesting that the benchmark available may provide an underestimate of income levels for 20234

2) Kenya Bureau of Statistics (2021) defines poverty line as Ksh 3,947 and Ksh 7,193 per person per month for rural and urban areas respectively in World Bank 2023: Kenya Poverty and Equity Assessment 2023, https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099121323073037589/p1773530a7eb3009308e3f08663aa95c826 3) World Bank 2023: Kenya Poverty and Equity Assessment 2023, https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099121323073037589/p1773530a7eb3009308e3f08663aa95c826 4) World Bank 2023: Kenya Poverty and Equity Assessment 2023, https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099121323073037589/p1773530a7eb3009308e3f08663aa95c826

I N T R O D U C T I O N

T RU S T

DATA

In both Kenya and Pakistan, our randomized sample of caregivers of adolescents skews towards higher vaccination rates K E N YA

PAK I STAN

Vaccination rates

COVID-19 vaccination (of respondent)

62%

38%

84%

16%

YES

Childhood vaccination (of child)

98%

YES

91%

YES

EXTERNAL DATA

HPV vaccination (of child) 63%

37%

YES

HPV vaccine rate

COVID-19 vaccine

Childhood vaccine

COVID-19 vaccine rate

33% have received the first dose and 16% have received the second by 20221.

Childhood vaccine rate

Approx. 32% of adults had received two doses by 20222.

Approx. 68%3 of children are vaccinated.

Approx. 64% of the population has received two doses.4

The national vaccine rate is approx. 76% 5

1) Karanja-Chenge, Christine Muthoni, 2022: “HPV Vaccination in Kenya: The Challenges Faced and Strategies to Increase Uptake. Front Public Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8978582/ 2) Statista, 2022: “Share of adult population fully vaccinated against COVID19 in Kenya as of July 9 2022, by county”. https://www.statista.com/statistics/1252641/share-of-population-fully-vaccinated-against-covid-19-in-kenyan-counties/ 3) Allen et al., 2023: Inequalities in childhood immunization coverage associated with socioeconomic, geographic, maternal, child and place of birth characteristics in Kenya. BMC Infectious Diseases . https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06271-9/tables/

We have reason to believe that this relative skew toward higher vaccination rates reflects our population of caregivers of adolescents • Our sample population is likely to be one of the most active groups of society. Parents to adolescents are often in the most productive age (mid twenties to late forties), and so, some of the most active citizens • Our sample ended up oversampling urban populations in both Kenya and Pakistan—a subpopulation that historically has been easier to reach in vaccine interventions. • Most recent benchmarks contain data from 2022. With data collection taking place in late 2023, vaccination rates for especially C19 and HPV may have improved since most recent benchmarks

4) Reuters COVID-19 Tracker, 2022: “Pakistan”. https://www.reuters.com/graphics/world-coronavirus-tracker-and-maps/countries-and-territories/pakistan/ 5) Unicef, 2021: “Country Office Annual Report 2021”. https://www.unicef.org/media/116341/file/Pakistan-2021-COAR.pdf

I N T R O D U C T I O N

O F

T H E

T R U S T

F R A M E W O R K

The four types of trust can be understood in isolation and through their relationships with each other—we call these quadrants and the relationships between them The Vaccine Trust Framework T RU S T I N T H E …

Health system promise

Vaccine promise

Does the health system have my and my community’s best interests at heart?

Do I believe that this vaccine has value for me and my community?

A U T O N O M Y F A I R N E S S P R I O R I T Y

In isolation, each quadrant can help explain vaccine uptake, and identify where to target trust-building efforts to ensure vaccine uptake…

… and combined, the four trust types form a holistic understanding of trust that can more robustly help predict and understand vaccine behavior

Zooming in one type of trust in isolation can provide deep understanding of the barriers to vaccine uptake and where to target trust efforts.

Looking at the four trust quadrants combined provides a robust understanding of trust that can help predict vaccine uptake – and shed light on the quadrants' interaction

B E N E F I T A L I G N M E N T

A C C E S S

Healthcare delivery Does the health system generally work for me and my community? C A P A B I L I T Y

R E L E VA N C E S A F E T Y

Vaccine delivery Do I feel this vaccine is available and accessible to me and my community?

A F F O R D A B I L I T Y C O M P E T E N C E

A D E Q U A C Y

O F

C O M P A S S I O N

D E L I V E RY

S E T T I N G

I N F O

C O N F I D E N T I A L I T Y

A G E N C Y

I N T R O D U C T I O N

O F

T H E

T R U S T

F R A M E W O R K

The Vaccine Trust Framework offers a picture of the trust landscape at a specific time—over time, it gives insights into the dynamic interactions among the four trust quadrants EXAMPLE:

MANDATED

YEAR 1 Health system promise

Healthcare delivery

VACCINES

YEAR 3

Vaccine promise

Vaccine delivery

A vaccine is pushed through despite low vaccine trust e.g., by mandate…

Health system promise

Healthcare delivery

YEAR 5

Vaccine promise

Vaccine delivery

… which decreases the trust in the health system over time…

Health system promise

Healthcare delivery

Vaccine promise

Vaccine delivery

… creating even lower trust levels for future vaccines

This is a key component of the Vaccine Trust Framework within low-trust contexts:

Every intervention has a trust impact – positive or negative – which eventually impacts trust in the overall health system 11

Introduction

Trust and the effect on vaccine uptake Trust and the effect on vulnerable groups Appendix

T R U S T

VA C C I N E

U P TA K E

When trust increases, so does the likelihood of vaccination – we call this the trust dividend

Across vaccines, building trust pays off Observed uptake

HPV

63%

73%

C19

62%

75%

Childhood vaccines

98%

>99%

C19

84%

95%

Childhood vaccines

91%

97%

PAK I STAN

Level of trust

Predicted uptake had trust been high1

K E N YA

The trust dividend

Predicted probability of vaccination

Plot: General trust’s effect on predicted likelihood of vaccination for HPV, COVID19, and childhood vaccines

*)Childhood vaccination rates are higher from the onset due to childhood vaccines' long history within maternal and pediatric healthcare and the nature of the data sample that skews towards higher childhood vaccination rates . 1) Predicted uptake with total trust at 80 on average 13

T R U S T

VA C C I N E

U P TA K E

At first glance, high trust in the vaccine promise drives significant uptake and matters more than high trust in other quadrants for vaccine uptake … ALL M ARGINAL

High trust in the vaccine promise drives real increases in likelihood of vaccination across vaccines with the following marginal effects C-19 vaccine

Childhood vaccines1

COVID-19 vaccine2

29 %-pts 61 %-pts

6 %-pts

12 %-pts

HPV vaccine

Avg. increase in likelihood to vaccinate as vaccine promise increases to 100 n = 1721

Avg. increase in likelihood to vaccinate as vaccine promise increases to 100 n = 2040

PAK I STAN

K E N YA

Avg. increase in likelihood to vaccinate as vaccine promise increases to 100

n = 3657

n = 3325

Childhood vaccines1

6 %-pts

Avg. increase in likelihood to vaccinate as vaccine promise increases to 100 n = 3476

Existing high childhood vaccine coverage reduces trust’s marginal effect on uptake— but trust still has a significant effect. 3

The marginal effect explains how a change in the trust score from 0100 influences the likelihood of vaccination on average.5 1) Childhood vaccines is defined as measles, hepatitis B, yellow fever, DFP or other vaccines the respondent characterizes as childhood vaccines. 2) In Pakistan, trust played a smaller role in COVID19 vaccination that was mandated upon the population. See more on slide 26

EFFECTS

3) The high prevalence of childhood vaccine makes increased trust less impactful when driving vaccine uptake, because vaccine coverage is high from the onset (98% in Kenya and 92% in Pakistan based on our sample ). 4) Statistically, the marginal effect represents the change in the probability of the dependent variable (vaccine uptake) due to a one-unit in the independent variable (trust) – in our case when trust goes from 0-100

HPV

C-19

Child C-19

Child

Health system promise

0%points (NS)

-19%points

-1%-8%points points (NS)

-3%points (NS)

Healthcare delivery

21%

-13% (NS)

11%

Vaccine promise

29%

61%

12%

Vaccine delivery

28%

34%

2% (NS)

1% (NS)

S U P P R E S S O R

E F F E C T

We are observing a suppressor effect when it comes to the relationship between trust in the health system promise and C-19 vaccination in both Kenya and Pakistan. This means the initial positive link between health system promise trust and C19 vaccination turns negative when accounting for other trust types.

T R U S T

VA C C I N E

U P TA K E

… But building trust in the vaccine promise takes time and may require extensive resources COVID-19

The COVID-19 pandemic revealed how difficult it is to make people trust that new vaccines are not only safe but also beneficial and relevant to them

VA C C I N E

HPV

“Building trust [in the COVID-19 vaccine’s benefits] is clearly desirable—and has many other benefits—but is a long-term project.”

It has proved particularly timeconsuming to build trust in the HPV vaccine promise, and even high trust countries have struggled with low uptake and critique.7

- Lenton et al (2022). “Resilience of countries to COVID-19 correlated with trust”. Nature

Key learnings from qualitative research

VA C C I N E

“Despite initial high trust, trust in HPV vaccination is currently being shaken in many European countries.” - Karafillakis et al (2019). “HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinates of GPV vaccine hesitancy in Europe”. Human Vaccines & immunotherapeutic

Trust in the COVID-19 vaccine promise was only established for those who worked in the the formal, economic sector

Caregivers hold low trust in the HPV vaccine promise and question the relevance to their children

Women outnumber men in Kenya’s informal sectors. In many cases, they operate outside of much government regulation, reducing the perceived benefit and relevance of vaccination. Mary, a 56-year-old chicken farmer from

Caregivers question the relevance of HPV vaccine Umaima, a 28-year-old mother won't vaccinate her daughters, because they don’t engage in “illicit sexual relationship” and the vaccine, therefore, isn’t relevant or beneficial to them.

Kisumu, can’t see much need for a vaccine.

T R U S T

VA C C I N E

U P TA K E

Therefore, relying solely on building trust in the vaccine promise can be risky—choosing which additional trust quadrant to prioritize depends on the objective: to build routine immunization or control and fight an epidemic Two typical vaccine rollout objectives…

Objective

Trust quadrant priority against the objective Risk of relying solely on vaccine promise

Build routine immunization

Control & fight an epidemic

Sustained efforts to ensure uptake—effectively reaching the last mile

Rapid uptake—effectively reaching most people fast

Healthcare delivery

Vaccine delivery

Building trust in a vaccine promise is often vaccine-specific and rarely spill over from one vaccine to another. When repeated vaccine behavior is the goal, trust in a vaccine promise doesn’t sustain repeated vaccination behavior, but mostly helps generate demand for specific vaccines.

Building trust in a vaccine promise is time-consuming and doesn’t immediately drive vaccine uptake. When rapid uptake is crucial, building trust in the vaccine promise is inefficient, and the effects on vaccine uptake are too delayed to rapidly achieve control.

T R U S T

V A C C I N E

U P T A K E

B U I L D

R O U T I N E

I M M U N I Z AT I O N

Build routine immunization

Control & fight an epidemic

Sustained efforts to ensure uptake— effectively reaching all and the last mile

Rapid uptake—effectively reaching most people fast

Healthcare delivery

Vaccine delivery

T R U S T

VA C C I N E

U P TA K E

BUILD

ROUTINE

IMMUNIZATION

To effectively drive vaccine uptake over time, it pays off to invest in building trust both in healthcare delivery and in the vaccine promise Plot: Average marginal effects of trust quadrants on vaccine uptake for HPV in Kenya and childhood vaccines in Pakistan

K E N YA

HPV vaccine In Kenya, healthcare delivery and vaccine promise strongly contribute to HPV-vaccine uptake. While vaccine delivery also plays a role, prioritization of resources should target both vaccine and system trust to leverage existing infrastructure.

Childhood vaccines1 PAK I STAN

Combined, trust in healthcare delivery and vaccine promise form a powerful relationship between system and vaccine trust to increase uptake in the long-term

For childhood vaccines in Pakistan, healthcare delivery and vaccine promise have the strongest effects on uptake relative to the other quadrants.

H E A LT H C A R E D E L I V E RY

21%-pts

Avg. increase in HPV uptake as healthcare delivery trust increases from 0-100

VAC C I N E

P RO M I S E

Avg. increase in HPV

as vaccine promise 29 %-pts uptake trust increases from 0-100

H E A LT H C A R E D E L I V E RY

5 %-pts

Avg. increase in childhood vac. uptake as healthcare delivery increases from 0100

VA C C I N E

P RO M I S E

Avg. increase in childhood

uptake as vaccine 6 %-pts vac. promise increases from 0100

1) Childhood vaccines is defined as measles, hepatitis B, yellow fever, DFP or other vaccines the respondent characterizes as childhood vaccines

T R U S T

V A C C I N E

U P T A K E

B U I L D

R O U T I N E

I M M U N I Z AT I O N

High trust in the vaccine promise helps establish resilient demand—even for the people with the lowest trust in vaccine delivery QUA LI TATI V E I NSI G HT

High trust in the vaccine promise can compensate for lower trust in the vaccine delivery Plot: Predicted probability of vaccination for HPV in Kenya and Childhood vaccines in Pakistan for fixed levels of vaccine delivery trust, as vaccine promise trust increases H P V

—

K E N YA

When a vaccine promise speaks to a salient fear, caregivers are willing to overlook low trust in the vaccine delivery

C H I L D . VA C 1 — P A K I S T A N

98% probability of HPV vaccination if trust in the vaccine promise is at 80, and trust in the vaccine delivery at minimum

47% probability of HPV vaccination if trust in the vaccine promise is at 80, and trust in the vaccine delivery at minimum

In Kenya, we observe a notable increase in HPV uptake for all levels of vaccine delivery trust as vaccine promise trust increases, including those with minimal trust in the vaccine delivery

47% Probability of HPV vaccination with vaccine promise at 80, and vaccine delivery at minimum

0.8 In Pakistan, high vaccine promise trust can also compensate for low trust in vaccine delivery, leading to high childhood vaccines coverage for all levels of vaccine delivery

1) Childhood vaccines is defined as measles, hepatitis B, yellow fever, DFP or other vaccines the respondent characterizes as childhood vaccines 2) Coverage is already high in our sample (91%) producing high baseline vaccination rates

98% Probability of HPV vaccination with vaccine promise at 80, and vaccine delivery at minimum 1

Katundu, a 67-year-old caregiver was thrilled to learn she could protect her granddaughter against cancer and, thereby, protect her future. With high trust in the promise, Katundu was willing to disregard her concerns about the vaccine delivery e.g., that would take place at schools.

“I was very happy because it meant that if she got vaccinated, she would be safe from cancer” - Katundu (67, KE)

T R U S T

V A C C I N E

U P T A K E

B U I L D

R O U T I N E

I M M U N I Z AT I O N

In addition, high trust in healthcare delivery independently increases vaccine uptake—and it appears to hold the potential to ease future vaccine rollouts by lifting the effect of trust in vaccines There are early indications that high trust in healthcare delivery can ease High trust in healthcare delivery drives additional vaccine uptake future roll-outs K E N YA

Q U A L I T A T I V E

K E N YA

HPV vaccine

21%-pts

Avg. increase in HPV vaccine uptake as healthcare delivery increases from 0-100 n = 1721

PA K I STAN

Childhood vaccines

6 %-pts

Avg. increase in childhood vaccine uptake as healthcare delivery increases from 0-100 n = 3476

1) Childhood vaccines is defined as measles, hepatitis B, yellow fever, DFP or other vaccines the respondent characterizes as childhood vaccines

I N S I G H T

Q U A N T I A T I V E

When people trust their healthcare delivery, they are more likely to trust vaccines from the onset Amy holds high trust in healthcare delivery – finding healthcare to be accessible and health providers trustworthy. When introduced to the HPV vaccine, she accepted it without hesitation, displaying confidence in both its availability and its potential benefits.

Trust in vaccines2 appear to have a slightly bigger impact on vaccine uptake when trust in the healthcare delivery is high

+3%-pts “I’ve gone ahead and given the HPV vaccine to my daughter.”

– Amy, CHV (KE)

2) Trust in vaccines compounds the two vaccine-specific quadrants, vaccine promise and vaccine delivery 3) Defined as the highest quartile of healthcare delivery : 72 in Kenya 4) When trust in the vaccine increases from 0-100 and controlling for the other trust types

I N S I G H T

Effect when high trust in the vaccine is combined with a high trust in the healthcare delivery

When comparing people in the highest quartile3 of healthcare delivery trust with the rest, the marginal effect of increasing trust in the vaccine on the likelihood of HPV vaccination appears to be bigger, while not significant.4 (p>0.1). 20

T R U S T

V A C C I N E

U P T A K E

B U I L D

R O U T I N E

I M M U N I Z AT I O N

A lack of trust in the delivery of healthcare introduces a negative spillover to vaccine uptake—even when people do trust a specific vaccine Plot: General trust & HPV/childhood vaccine for lowest quartile of health delivery trust compared to rest

K E N YA

HPV vaccine

The difference in marginal effect of trust in the vaccine between those in lowest quartile of trust in health delivery compared to rest3

-19%-points difference in effect of trust in the HPV vaccine for those in lowest quartile of healthcare delivery trust compared to rest

For people with low trust in healthcare delivery,1 building trust in the HPV vaccine has a smaller effect on uptake compared to the rest of the population

Trust dividend for low trust in healthcare delivery

Trust dividend for medium to high trust in healthcare delivery

Childhood vaccines2 PA K I STA N

Low trust in healthcare delivery partly outweighs the positive effect of trust in vaccine promise, or in the most severe cases, completely outweighs its effect—making high trust in health delivery a critical lever to lift vaccine uptake

For people with medium to high trust in healthcare delivery, building trust in childhood vaccines1 increases the already high uptake—but for those with low trust in healthcare delivery,1 we barely see an effect

1) Lowest quartile of healthcare delivery: 54 in Kenya, 54 in Pakistan 2) Childhood vaccines is defined as measles, hepatitis B, yellow fever, DFP or other vaccines the respondent characterizes as childhood vaccines 3) When trust in the vaccine increases from 0-100 and controlling for the other trust types

No trust dividend for low trust in healthcare delivery, with slope remaining flat

Trust dividend for medium to high trust in healthcare delivery

-7%-points difference in effect of trust in the C19 vaccine for lowest quartile of healthcare delivery trust compared to rest

0.5

-19%-pts

Average difference in effect of increasing vaccine trust between low healthcare delivery trust1 and rest

The difference in marginal effect of trust in the vaccine between those in lowest quartile of trust in health delivery compared to rest3

-7%-pts.

Average difference in effect of increasing vaccine trust between low healthcare delivery trust1 and rest

T R U S T

V A C C I N E

U P T A K E

B U I L D

R O U T I N E

I M M U N I Z AT I O N

Zero dose & rejectors: When comparing those who accept and those who reject vaccines, rejectors have significantly lower trust scores than accepters—especially in the vaccine promise and delivery T RU S T

K E N YA

PA K I S TA N C H I L D. VAC . 2

H P V- VA C .

Health system promise

SCORES

Rejected1

Accepted1

Rejected1

Accepted1

/100

Healthcare delivery

Vaccine promise

Vaccine delivery

/100

n = 127

/100

n = 890

/100

C H I L D. VAC . 2

/100

Health system promise

/100

Healthcare delivery

Rejected1

Accepted1

65 61

64 61

/100

Vaccine promise

Vaccine delivery

/100

n = 57

/100

n = 3595

In Kenya, caregivers rejecting the HPV vaccine or childhood vaccines have lower trust in the vaccine—notably, caregivers rejecting childhood vaccines also have lower trust in the system, whereas HPV vaccine rejectors have similar trust in the system as accepters and only low trust in the vaccine itself.

/100

n = 317

/100

n = 3405

In Pakistan, both rejectors and accepters have low trust in the system, while caregivers rejecting childhood vaccines also have lower trust in the vaccines— especially the vaccine’s promise where the difference is 9%-point.

1) “Rejected” are defined as respondents who answered ”Yes” to being offered the vaccine, but “No” to having received it. “Accepted” are defined as respondents who answered “Yes” to being offered and receiving the vaccine. 2) Childhood vaccines is defined as measles, hepatitis B, yellow fever, DFP or other vaccines the respondent characterizes as childhood vaccines

T R U S T

V A C C I N E

U P T A K E

B U I L D

R O U T I N E

I M M U N I Z AT I O N

Zero dose & rejectors: The type of trust that consistently appears to have the biggest impact for reaching all children—including children of vaccine rejectors—is trust in the vaccine promise The people who reject vaccines for their children especially lack trust in the vaccine promise, suggesting that this trust type is crucial to drive uptake. Trust in vaccine promise unites three dimensions1—trust in the benefit, relevance, and safety of a vaccine, all of which are lower for caregivers who have rejected vaccines for their children.

K E N YA T R U S T

B E N E F I T R E L E VA N C E S A F E T Y

B E N E F I T

R E L E VA N C E

The perceived relevance of being protected against disease for child and community

S A F E T Y

The perceived risk of side effects or other adverse events

1) For an overview of all trust dimensions, see appendix 2 2) Childhood vaccines is defined as measles, hepatitis B, yellow fever, DFP or other vaccines the respondent characterizes as childhood vaccines

HPV

C H I L D. VA C 2

Rejected

Accepted

Rejected

Accepted

78 68 42

94 84 58

77 62 54

96 80 69

/100

n = 127

/100

n = 890

/100

n = 57

/100

n = 3595

PAKI S TA N T R U S T

The perceived value of the vaccine to child and community

S C O R E S

B E N E F I T R E L E VA N C E S A F E T Y

C H I L D. VA C 2 Rejected

Accepted

72 55 60

88 65 65

/100

n = 317

/100

“Rejected” are defined as respondents who answered ”Yes” to being offered the vaccine, but “No” to having received it. “Accepted” are defined as respondents who answered “Yes” to being offered and receiving the vaccine.

n = 3405 23

T R U S T

VA C C I N E

U P TA K E

C O N T R O L

F I G H T

A N

E P I D E M I C

Build routine immunization system

Control & fight an epidemic

Sustained efforts to ensure uptake – effectively reaching all and the last mile

Rapid uptake – effectively reaching most people fast

Healthcare delivery

Vaccine delivery

T R U S T

VA C C I N E

U P TA K E

C O N T R O L

F I G H T

A N

E P I D E M I C

Trust in vaccine delivery is a crucial component to rapid uptake—but in isolation, trust in vaccine delivery is not enough to drive the rapid uptake needed in an epidemic Vaccine delivery trust is relatively tangible for policy-makers to influence and helps ensure vaccine access crucial to widespread reach during a pandemic Vaccine delivery trust compounds perception of information distribution, vaccination sites, and consent processes1—all factors influenced by policy choices. Independently, vaccine delivery trust increases likelihood of C19 vaccination with the following average effects as it increases from 0-100: K E N YA

P A K I S T A N

35 %-pts

9 %-pts.

Vaccine delivery’s average effect on C-19 uptake2

n = 2040

n = 3325

1) For breakdown of all trust dimensions, see Appendix 2. 2) When trust in the vaccine delivery increases from 0-100 and controlling for the other trust types

In practice, vaccine delivery can’t stand alone: C19 roll-outs in Kenya and Pakistan demonstrate how it was leveraged in combination with… Trust in vaccine promise: Vaccination as a personal choice

Force: Vaccination as a mandated measure

In Kenya, the C19-vaccine roll out was administered through healthcare facilities. While a minority of the Kenyan workforce was required to be vaccinated to work, vaccination was, in practice, largely choice- and access-based. People’s vaccination decisions relied on the vaccine being accessible to them, and their belief in its promise.

In Pakistan, the C19-vaccine roll-out was administered by the Pakistani military as a mandated intervention in the interest of containing the pandemic. While some citizens were willing to self-vaccinate once the vaccine was made accessible to them, the high C-19 vaccine coverage was also a product of force.

T R U S T

VA C C I N E

U P TA K E

C O N T R O L

F I G H T

A N

E P I D E M I C

Kenya exemplifies how building trust in the vaccine delivery has a strong, positive trust dividend on uptake if combined with a moderate level of trust in the vaccine promise Plot: Predicted C19 vaccination in Kenya for fixed levels of vaccine promise trust, as vaccine delivery trust increases

K E N YA

In Kenya, trust in vaccine delivery and vaccine promise increases C19 uptake— combined, we observe that for vaccine promise, ‘a little trust goes a long way’ to obtain high coverage

70% predicted vaccination rate for median vaccine promise, and vaccine delivery at 80 58% predicted vaccination rate for lowest quartile of vaccine promise, and vaccine delivery at 80

Increasing trust in vaccine delivery increases likelihood of C19 vaccination for all levels of vaccine promise trust, but the effect is lower for those with minimal trust in the C19 vaccine promise—and not enough on its own to secure containment due to low baseline vaccination rates.

Predicted probability of C19-vaccination for different levels of vaccine promise trust, had vaccine delivery been high

Increase in uptake as vaccine promise goes from minimum to 1st quartile

19% predicted vaccination rate for minimum vaccine promise, and vaccine delivery at 80

Vaccine promise trust Predicted probability of C19-vaccination with vaccine delivery trust at 80

M I N I M U M

L O W E S T Q U A RT I L E

M E D I A N

19%

58%

70% 26

T R U S T

VA C C I N E

U P TA K E

C O N T R O L

F I G H T

A N

E P I D E M I C

In Pakistan, combining trust in the vaccine delivery with a mandate resulted in high vaccine uptake Plot: Predicted C19 vaccination in Pakistan for fixed levels of vaccine promise trust, as vaccine delivery trust increases

92% predicted probability of C19 vaccination

87% predicted probability of C19 vaccination

PAK IS TA N

80% predicted probability of C19 vaccination 68% predicted probability of C19 vaccination

Vaccine promise trust Predicted probability of C19vaccination with vaccine delivery trust at minimum

In Pakistan, the C19 roll-out combining vaccine delivery efforts with a mandate to be vaccinated affects predicted uptake in two distinct ways… High baseline vaccination rates despite low levels of trust: For Pakistan, we observe high baseline vaccination rates for all irrespective of trust in the C19 vaccine promise and delivery, suggesting that force played a significant role in ensuring uptake Vaccine delivery trust has a strong effect for the least trusting in the C19 vaccine promise: In parallel, we observe that the effect of vaccine delivery trust is particularly strong for those with minimal trust in the vaccine promise—its benefit, efficacy and safety—most likely accelerated by the mandate

M I N I M U M

L O W E S T Q U A R T I L E

68%

80%

Vaccine promise trust Predicted probability of C19vaccination with vaccine delivery trust at 80

M I N I M U M

L O W E S T Q U A R T I L E

87%

92% 27

T R U S T

VA C C I N E

U P TA K E

C O N T R O L

F I G H T

A N

E P I D E M I C

While trust in vaccine delivery combined with a mandate effectively ensured uptake, the strategy appears to have eroded trust in the health system, potentially jeopardizing future vaccine rollouts QUA LI TATI V E

INSIGHT

The mandate appears to have caused trust erosion in the Forced vaccination undermines trust in vaccines more broadly – promise of the Pakistani health system, and especially two and have raised the bar for how much trust is needed to accept future vaccines subdimensions1 are impacted — Autonomy and Fairness

Autonomy

Fairness The perception that the health system provides services in a non-discriminatory manner

C 1 9

SCORES

C O N S E N T

B R E AC H E D

/100

n = 964

C 1 9

R E S P E C T E D

/100

n = 21193

C O N S E N T

R E S P E C T E D

B R E AC H E D

55 n = 964

/100

“In my hearts of hearts, I do not trust these vaccines. Only God knows what's in [them]… I will not be forced into it again, I promised myself ”

INSIGHT

The perception that the health system recognizes people’s autonomy to make decisions about own health

n = 964 out 3325 vaccinated

T RU S T

For Ghazala, a 50-year-old housewife, the mandated COVID-19 experience made her question the health system and vaccines more broadly. She is conflicted about the benefits of vaccines and has promised herself never again to accept a vaccine she does not fully understand or believe in – raising the bar for how much trust Ghazala needs to accept future vaccine. What we call a negative trust dividend.

QUA LI TAT I V E

26%

of caregivers vaccinated against COVID-19 report that their consent was breached2

– Ghazala (50, PK). COVID19 vaccinated in the summer of 2021. Interviewed February 2023

/100

n = 21193

1) For breakdown of trust dimensions, see Appendix 2 2) By ‘consent breach’ we mean either a) respondent was not asked for their consent, or b) their decision was not respected 3) 242 have not answered the questions about consent in the COVID19 context.

Introduction Trust and the effect on vaccine uptake

Trust and the effect on vulnerable groups Appendix

T R U S T

V U L N E R A B L E

G R O U P S

Trust has a significant potential to help reach populations often otherwise left behind in public health

4.5 billion

people are not fully covered by essential health services1 – disproportionately affecting women and marginalized groups2

Marginalized groups*

Women

T RU S T O P P O RT U N I T Y

For the most marginalized, the effect of trust on vaccine uptake is just as strong as for others— making trust an equitable measure that lifts all groups

Trust drives women to action before men when women have health decision power—making trust a lever to lift women’s health

SITUATION TO DAY

Essential health service coverage is especially low among marginalized groups such as rural geographies, low income, and unemployed groups.3

Many women lack access to essential healthcare services, especially when it comes to sexual and reproductive health5 – this is particularly paramount for marginalized women, e.g., women in rural areas and low-income groups.6

* Definition Marginalized groups

People within a given culture at risk of being subjected to multiple discrimination due to the interplay of different personal characteristics or grounds, such as ethnicity, health status, gender, or income, or living in various geographic localities.4

1) WHO Definition: The average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and the most disadvantaged population . 2), 3) & 6) WHO, 2023: “Tracking Universal Health Coverage, 2023 Global Monitoring Report.” https://iris.who.int/bitstream/handle/10665/374059/9789240080379-eng.pdf?sequence=1 5) WHO, 2022: “Protecting the promise: 2022 progress report on the every women every child global strategy for women’s, children’s and adolescents’ health (2016-2030)”. https://www.who.int/publications/i/item/9789240060104 4) European Institute for Gender Equality, 2023. https://eige.europa.eu/publications-resources/thesaurus/terms/1175?language_content_entity=en

T R U S T

V U L N E R A B L E

G R O U P S

M A R G I N A L I Z E D

G R O U P S

When building trust, marginalized groups show increased vaccine uptake, just like the rest of the population, suggesting trust as an equitable measure to increase vaccine uptake for all The likelihood of nondominant language speakers2 to be vaccinated increases significantly and comparably to the rest when general trust1 increases.

PAK I STAN

K E N YA G E N E R A L T RU S T H P V VAC C I N E

& Comparable effect of trust on vaccine uptake Comparable effect of trust on vaccine uptake

G E N E R A L T RU S T C H I L DVA C .

Marginalization measured by …

Definition: Survey language

Answering the survey in a nondominant language often signifies political and financial marginalization The same comparable effect is observed when comparing geographically marginalized groups with the rest. See appendix 5

Non-dominant language n = 812

Kiswahili/English n = 2854

Non-Urdu n = 706

Urdu n = 3027

There is no significant difference between the effect of trust on vaccine uptake between dominant language speakers (English/Kiswahili) and non-dominant language speakers2 in Kenya or Urdu and non-Urdu speakers2— suggesting that the effect of trust in HPV and childhood vaccination is comparable for marginalized and the rest of the population in both Kenya and Pakistan.

1) Trust, in this case, refers to a total trust score that compounds all four trust quadrants for given vaccine 2) Non-dominant languages in Kenya: Kikuyu, Kikamba, Luhya, Somali, Kisii, Luo, Nadi, Turkana, Maasai; Non-dominant languages in Pakistan: Punjabi, Sindhi, Pushto/Pashto, Balochi, Kashmiri, Hindko, Brahvi. See appendix 4 for a more detailed explanation of the choice of language and regions

T R U S T

V U L N E R A B L E

G R O U P S

M A R G I N A L I Z E D

G R O U P S

We use language as a proxy for marginalization—marginalized language groups have lower trust scores than the rest of the population Measuring marginalization through survey language,1 we observe lower trust levels compared to majority groups

H P V K E N YA

VA C C I N E AVG . 2 PA K I S TA N

Marginalized groups

Rest of pop.

66 < 69 /100

Non-dominant language

Definition: Survey language

Answering the survey in a nondominant language often signifies political and financial marginalization

1) Non-dominant languages in Kenya: Kikuyu, Kikamba, Luhya, Somali, Kisii, Luo, Nadi, Turkana, Maasai; Nondominant languages in Pakistan: Punjabi, Sindhi, Pushto/Pashto, Balochi, Kashmiri, Hindko, Brahvi. See appendix 4 for a more detailed explanation of the choice of language and regions

Non-dominant language n = 812

English/ Kiswahili n = 2854

/100

n = 2854

Health system promise

61 66

/100

Healthcare delivery

Vaccine promise

Vaccine delivery

/100

Rest of pop.

64 < 67

/100

English/Kiswahili

n = 812

Marginalization measured by …

Marginalized groups

On a trust quadrant level, marginalized language groups in Kenya especially exhibit lower trust in the promise of the health system and the HPV vaccine.

Non-Urdu

Urdu

n = 706

n = 3027

Health system promise Non-Urdu n = 706

Urdu n = 3027

63 65

/100

Healthcare delivery

Vaccine promise

Vaccine delivery

/100

In Pakistan, marginalized language groups are less trusting in the average vaccine promise and vaccine delivery than rest of pop. 2) Vaccine trust scores calculated as average vaccine promise and vaccine delivery for C19 and childhood vaccines

/100

T R U S T

V U L N E R A B L E

G R O U P S

M A R G I N A L I Z E D

G R O U P S

As for marginalized geographical regions, North Eastern in Kenya and Baluchistan in Pakistan exhibit low trust scores Measuring marginalization through geography1, distinct patterns emerge for North Eastern in Kenya, and Baluchistan in Pakistan

H P V K E N YA

Marginalized groups

Regional variation covers different political, economic, and security situations across a country

57 < 68 /100

Rest of Kenya

n = 119

n = 3551

Health system promise North Eastern region n = 119

Baluchistan 1) See appendix 4 for a more detailed explanation of the choice of language and regions

/10

Rest of Kenya

/100

Marginalized groups

/100

Healthcare delivery

Vaccine promise

Vaccine delivery

/100

Rest of pop.

62 < 66

/100

n = 3551

North Eastern

Rest of pop.

North Eastern

Marginalization measured by …

Definition: Geography

VA C C I N E AVG . 2 PA K I S TA N

Rest of Pakistan

n = 178

n = 3556

Health system promise Baluchistan

/10

n = 706

/100

Healthcare delivery

Vaccine promise

Vaccine delivery

/100

In Kenya, the North Eastern region exhibits drastically lower trust in the promise of the health system and the HPV vaccine, as well as in the HPV vaccine delivery.

Rest of Pakistan /100

n = 3027

/100

Baluchistan

/100

In Pakistan, the Baluchistan region is less trusting in the average vaccine promise and vaccine delivery than rest of pop. 2) Vaccine trust scores calculated as average vaccine promise and vaccine delivery for C19 and childhood vaccines

T R U S T

V U L N E R A B L E

G R O U P S

M A R G I N A L I Z E D

G R O U P S

And are often less likely to be vaccinated or accept vaccines on behalf of their children—even with the sample’s higher vaccination rates VA C C I N AT I O N R AT E S

BASED

ON THE

T RU S T

S U RV E Y

K E N YA

PA K I S TA N

In Kenya, marginalized groups – especially people in the North Eastern region – exhibit lower vaccine rates

Similarly, marginalized groups in Pakistan, especially in Baluchistan, exhibit lower vaccine rates

98%

100%

0.96 0.98

87%

90%

66%

50%

0.64 0.57

63%

0.64 0.59

70%

74% 66%

50%

43%

40%

30%

20%

10%

HPV COVID19 Childhood HPV COVID19 Childhood vaccination vaccination vaccination vaccination vaccination vaccination rate rate rate rate rate rate

North Eastern English/Kiswahili

82%

0.91 0.88

0.84 0.83

60%

40%

84%

80%

60%

10%

92%

90%

80% 70%

100%

Rest of Kenya

Non-dominant language

7% HPV awareness

COVID19 vaccination rate

Baluchistan

Childhood vaccination rate

Rest of Pakistan

COVID19 vaccination rate

Non-Urdu

Childhood vaccination rate

Urdu 34

T R U S T

V U L N E R A B L E

G R O U P S

W O M E N

In general, women have higher trust scores compared to men—both in the healthcare system and in specific vaccines T RU S T

K E N YA

SCORES

PA K I S TA N

WOMEN

MEN

/100

n = 2946

n = 724

QUA DR ANT

/100

Women in Kenya are more more trusting than men – especially in the promise of the health system and the vaccine

WOMEN

MEN

/100

n = 2482

Women in Pakistan are more trusting than men— especially in healthcare delivery /100

n = 1252

L E V E L T RU S T

Health system promise

Healthcare delivery

Vaccine promise

Vaccine delivery

Health system promise

Healthcare delivery

Vaccine’s promise

Vaccine delivery

/100

In Kenya, women are significantly more trusting overall compared to men. This is driven especially by women’s higher trust in the promise of the healthcare system, and the vaccine promise.

In Pakistan, women are also significantly more trusting overall compared to men. This is especially driven by women’s higher trust in healthcare delivery, and in the vaccine delivery. 35

T R U S T

V U L N E R A B L E

G R O U P S

W O M E N

Any level of trust has a higher effect on vaccine uptake for women than men when women report to have health decision power—making trust a key instrument to lift women’s health Definition: Health decision power Respondents who have answered “I am in charge of child health decisions” to the question “Who in your household is most in charge of child health decisions, such as when and where to seek care when a child is sick?” are defined to hold health decision power. Women with health decision power:

72%

of the women in Kenya identified themselves as the main decision-maker when it came to their child’s health (n = 2121)

37%

of the women in Pakistan identified themselves as the main decision-maker when it comes to their child’s health (n = 912)

Trust drives women to act before men when women have health decision power: Women will then accept a vaccine on substantially lower levels of trust in the vaccine compared to men K E N YA

70% likelihood of HPV vaccination

Women Trust score on 72

Men Trust score on 92

A trust score difference of 20 points to achieve the same predicted vaccine uptake

1) The data sample in Kenya skews towards higher income groups. This might result in a higher share of women who report to have health decision power compared to the true population.

Women with health decision power have 70% likelihood of HPV vaccinating their adolescent with a general trust score on 72… … Men with health-decision power, however, need a general trust score on 92 to reach a 70% likelihood of HPV vaccinating their adolescents This effect persists across vaccines in Kenya, where women report to have high health decision power1 but not in Pakistan. 36

T R U S T

V U L N E R A B L E

G R O U P S

W O M E N

When women’s trust is at risk, it is primarily driven by fear that their consent will be compromised

There are indications1 that the pattern of higher trust among women doesn’t hold when looking at the dimension of agency*, defined as trust in the process of informed consent K E

Unemployed women3 exhibit significant lower trust in vaccine delivery compared to employed women—driven by a lack of trust in the process of consent collection H P V

K E N YA

C 1 9

P A K I S T A N

Subset: Below the poverty line

EMPLOYED

UNEMPLOYED

Trust in agency is critically low for women in Kenya with monthly incomes below the national poverty line. However, for women below the poverty line in Pakistan, the pattern becomes less distinct

P K

HPV

C19

Trust in agency

Trust in vaccine delivery unites three dimensions:2 A D E QUAC Y

O F

D E L I V E RY

S E T T I N G

EMPLOYED

General trust

70 67

The perceived adequacy of consent collection, incl. whether people trust they will be asked for their consent and whether this decision is respected 1) Difference between genders are insignificant (p>0.05), yet breaks observed pattern of women having higher trust than men 2) For an overview of all trust dimensions, see appendix 2

/100

/10

68 67 /100

/100

H P V EMPLOYED

Trust in the vaccine delivery

72/100

Trust in agency

63/100

I N F O

AG E N C Y

UNEMPLOYED

n = 2178

/100

n = 766

/100

n = 766

76/100

/100

72/100

n = 2251

n = 570

73/100

55/100

n = 226

n = 2251

n = 226

/100

n = 570

K E N YA

C 1 9

UNEMPLOYED

EMPLOYED

/100

n = 275

/100

n = 275

P A K I S T A N

74/100 n = 570

71/100 n = 570

UNEMPLOYED

/100

n = 275

/100

n = 275

This may speak to country-specific contexts, with Kenya generally offering more possibility for women’s decision-making, and so, the lack of agency is felt and perceived more strongly—whereas in Pakistan, women’s room for decision-making is limited,5 suggesting that own agency is less of a focus for the most vulnerable women. 3) Unemployed is defined as women who ”don’t engage in activities for which they are paid in cash or kind”. The definition builds on the World Bank’s definition and is adjusted to the LMIC context with input from the project’s gender advisors. https://databank.worldbank.org/metadataglossary/world-development-indicators/series/SL.IND.EMPL.ZS 4) Poverty lines in Kenya defined as Ksh 3,947 and Ksh 7,193 per person per month for rural and urban areas respectively, as defined by the Kenya Bureau of Statistics (2021) in World Bank 2023: “Kenya Poverty and Equity Assessment 2023”; For Pakistan, the national poverty line is calculated as USD 3.65 per person per day (30.000 PKR per month) in World Bank (2023): “Poverty and Equity Brief Pakistan “ 5) With Pakistan marked by caste stratification and patriarchal structures, women’s position in the social hierarchy is more vulnerable

Introduction Trust and the effect on vaccine uptake Trust and the effect on vulnerable groups

Appendix

Appendix 1

Appendix 2

Overview of methodological considerations

Overview of trust dimensions

Appendix 3

Appendix 4

Appendix 5

Appendix 6

Multicollinearity

Definition of marginalization by survey language and geography

Trust & marginalized geographies

Sample composition

A P P E N D I X

Appendix 1: How The Trust work solves for the four challenges with existing trust measures

CHALLENGES

Trust measures are situational and imprecise

There is a lack of agreement on what trust is

Most trust measures are Western-centric

Trust measures are removed from decision-making

SOLUTIONS • The survey has been developed based on two rounds of detailed qualitative research

• Health- and vaccine-related trust have been operationalized meticulously

• The survey has undergone both

to capture their multiple dimensions and optimize measurement validity

ensure that it is fit-for-purpose and that central concepts are understood • The survey integrates trust and vaccine measures to bring the two fields together

• Existing validated items from the literature have been used

expert review, cognitive testing, and pilot testing to

to the extent possible to further advance the field

• The survey has first and foremost been developed and validated for use in LMIC contexts, which have particular dynamics that aren’t captured by Westerncentric measures • The survey enables testing of hypotheses linking trust to vaccine acceptance in LMIC

contexts – and identification of relevant proxies for situations where a particular vaccine hasn’t been introduced yet

• Key decision makers both globally and nationally have been engaged from the outset

of the work to design a relevant data tool for their use cases • Data has been collected to not

only map trust nationally but also regionally, with an aim to

inform targeted approaches and interventions to drive trust and vaccine uptake

A P P E N D I X

Appendix 2: Overview of the dimensions of trust that constitute each trust quadrant

Health system promise

Vaccine promise

The perception that the health system recognizes people’s autonomy in making decisions about their own health

AU TO N O M Y

The perceived value of the vaccine to child and community

B E N E F I T The perception that the health system provides services in a non-discriminatory manner

FA I R N E S S

P R I O R I T Y

A L I G N M E N T

The perception that the health system works towards the same kinds of health outcomes as people The health system’s perceived ability to deliver on people’s expectations of treatment of issues that fall within the purview of the system

C A PA B I L I T Y

The perceived relevance of being protected against disease for child and community

R E L E VA N C E

The perceived risk of side effects or other adverse events

S A F E T Y

Healthcare delivery AC C E S S

The perceived ease of accessing healthcare – incl. distance, time, navigation, language barriers, and availability of medical provisions

A F F O R DA B I L I T Y

The perceived ability to get healthcare when needed without having to forego or delay treatment due to cost

C O M P E T E N C E

The perception that healthcare providers have the knowledge and skills required to attend to people’s issues

C O M PA S S I O N

The perception that providers engage patients with respect and recognition, and demonstrate a commitment to their betterment

C O N F I D E N T I A L I T Y

The perception that medical and personal information will be kept private and undisclosed outside the provider/patient relationship

Vaccine delivery A D E QUAC Y

O F

I N F O

The perceived completeness of the information provided about the vaccine

D E L I V E RY

S E T T I N G

The percieved appropriateness of the site(s) where the vaccine is delivered, including medical competence and safety when accessing the vaccine

AG E N C Y

The percieved adequacy of consent collection, including whether people trust they will be asked for their consent and whether their decision will be respected

A P P E N D I X

Appendix 3: Our data shows multicollinearity when analyzing all four trust quadrants—but results remain statistically significant throughout when predicting vaccination behavior The Trust Framework conceptualizes trust as four related trust types, making multicollinearity a premise for analysis The trust quadrants display low to moderate pairwise correlation—however, Variance Inflation Factors (VIF) are high (+10), suggesting that the combination of trust quadrants drive multicollinearity, and in turn, increases uncertainty PA I RW I S E C O R R E L AT I O N * Health promise

Healthcare delivery

Vaccine promise

VIF ANALYSIS* Vaccine delivery

Health promise

0.4

0.2

0.26

Healthcare delivery

0.4

0.19

0.22

Vaccine promise

0.2

0.19

0.4

Vaccine delivery

0.26

0.22

0.4

*) Calculated based on results from Kenya on the HPV vaccine

Despite multicollinearity, we observe significant results across analyses of the four trust quadrants This indicates that although results are subject to higher statistical uncertainty, trust comes out as a strong predictor of vaccine uptake. All results in this report are significant on at least ⍺ = 5% unless reported otherwise

A P P E N D I X

Appendix 4: To approximate marginalization, we have selected the variables survey language and geography K E N YA

Survey language: In Kenya, opting for a nondominant language in conversation with strangers indicates lower socioeconomic class and marginalization Speaking English or Kiswahili signals class in Kenya, and people will often choose these languages in conversations with strangers to signal their social status. When people opt for answering the survey in a different, non-dominant language, it signals both financial and political marginalization and is closely tied to people’s socioeconomic class.

Geography: The North Eastern region is one of the poorest and most politically marginalized regions in Kenya SECURITY SITUATION The Northeastern region suffers from ethnic clashes and cattle fights exacerbated by severe droughts and food insecurity. ECONOMIC SITUATION Approx. 70% of people in the Northeastern region live below the poverty line and the region suffers from infrastructure deficit, including few roads and limited access to water.

PAK I STAN

Survey language: Not preferring or not being able to speak Urdu often signals lower income and some degree of political marginalization in Pakistan In Pakistan, Urdu is the dominant political language. While taught in schools across the country, some population groups don’t speak or prefer to speak in their local language, which often signals distance to the political and financial elites and, thereby, potential marginalization.

Geography: Baluchistan is one of the most politically and financial marginalized regions in Pakistan SECURITY SITUATION For many years, Baluchistan has faced significant security issues along the Afghan border, destabilizing everyday life for the population. ECONOMIC SITUATION More than 60% of people in Baluchistan live below the poverty line and Baluchistan has historically housed a significant number of Afghan refugees, who live in temporary dwellings with poor infrastructure and access to healthcare

A P P E N D I X

Appendix 5: When building trust, geographically marginalized groups show increased vaccine uptake comparably to the rest—similar to the pattern observed for marginalized language groups n = 119

The likelihood of geographically marginalized respondents to be vaccinated increases significantly and comparably to the rest of the population groups when general trust2 increases*.

n = 178

n = 3551

n = 3556

PAK I STAN

K E N YA G E N E R A L T RU S T & GC EONV EI R T AR C U CS IT N & DA 1 9L V E H P V VAC C I N E

Comparable effect of trust effect of trust on vaccine uptake on vaccine uptake Comparable effect of trust on vaccine uptake

G E N E R A L T RU S T & G E N E R A L T RU S T & C H I L D VAC . C H I L DVA C . North Eastern n = 119

*Due to the small sample size in each region, the results are indicative of a pattern, but conclusions are less robust.

Rest of Kenya n = 3551

There is no significant difference between the marginal effect of trust on vaccine uptake between the North Eastern region and rest of Kenya, suggesting that the effect of trust on COVID-19 vaccine uptake is the comparable for geographical marginalized and the rest of the population.

2) Trust, in this case, refers to a total trust score that compounds all four trust quadrants for given vaccine

Baluchistan n = 178

Rest of Kenya n = 3556

There is no significant difference between the marginal effect of trust on vaccine uptake between Baluchistan and rest of Pakistan,suggesting that the effect of trust on childhood vaccines uptake is comparable for geographical marginalized and the rest of the population Pakistan as in Kenya.

Appendix 6: Sample composition

K E N YA

Demographic & socioeconomic profile

Health & vaccine profile

Geographical sample distribution

PA K I S TA N

Demographic & socioeconomic profile

Health & vaccine profile

Geographical sample distribution

S A M P L E

C O M P O S I T I O N

S U M M A RY

S TAT I S T I C S

K E N YA

Demographic & socioeconomic profile: Randomized sampling of caregivers to adolescents has resulted in a majority of younger, female respondents K E N YA n = 3 6 7 0

Age

Income

Median 36 years

Median 10 000 KES/month

42%

PETTY TRADER/SELF-EMPLOYED

26% 16% 9%

PROFESSIONAL, TECHNICAL, MANAGERIAL HOUSEHOLD, DOMESTIC, AND SERVICES

CLERICAL OR SALES

OTHER

UNEMPLOYED/RETIRED/HOUSEWIFE

49%

>65

PROTESTANT

26%

Complete secondary

24%

CATHOLIC

14%

OTHER CHRISTIAN

13%

Incomplete secondary

11%

MUSLIM

22%

Complete primary

17%

Incomplete primary

No education

*) Past Ipsos studies give reason to believe that this split – based on random sampling of caregivers in households – is a representative reflection of the true distribution.

Religion 16%

Higher than secondary

>25

12%

Education

Type of work AGRICULTURAL

5% 45-54

BOYS

35-44

GIRLS

25-34

44%

<25

56%

SKILLED AND UNSKILLED MANUAL LABOR

55-64

Child gender

15-25

14%

10-15

31%

22%

17%

8-10

MALE

22%

Thousand KES

6-8

FEMALE

43%

4-6

20%

2-4

80%

0-2

Respondent gender*

NONE

TRADITIONAL AFRICAN

OTHER

S A M P L E

C O M P O S I T I O N

S U M M A RY

S TAT I S T I C S

K E N YA

Health & vaccine profile: More than half of the sample have vaccinated their daughters against HPV, while the vast majority accept childhood vaccines K E N YA n = 3 6 7 0

Public/private healthcare

COVID-19 vaccination

82%

18%

PUBLIC

PRIVATE

Type of health service used for most of respondent’s health issues

38%

YES

Vaccination status of respondent

76%

24%

YES

Whether respondent has heard about the HPV vaccine

Child vaccination

Type of provider

HPV vaccination

47%

LOCAL HOSPITALS

42%

HEALTH DISPENSARIES

27%

REFERRAL HOSPITALS

23%

PHARMACIST

DOCTORS WITH THEIR OWN OFFICE

62%

HPV vaccine awareness

12%

98% YES Whether child has received at least one dose of measles, hepatitis B, yellow fewer, or tuberculosis vaccine

2% NO

63%

37%

YES

Whether child is vaccinated against HPV

Type of healthcare provider used for most of respondent’s health issues (multiple choice) – top 5 across respondents 46

S A M P L E

C O M P O S I T I O N

S U M M A RY

S TAT I S T I C S

PA K I S TA N

Demographic & socioeconomic profile: Randomized sampling of caregivers to adolescents has resulted in a majority of female respondents across income groups PA K I S TA N n = 3 7 3 4

Age Median 38 years

Respondent gender*

Type of work 30% 13%

SALARIED EMPLOYEE - GOV

11%

AGRICULTURAL

28%

Complete secondary

19%

Incomplete secondary

SKILLED LABOR CULTIVATOR

OTHER

15%

Incomplete primary

UNSKILLED LABOR

No education

*) Past Ipsos studies give reason to believe that this split – based on random sampling of caregivers in households – is a representative reflection of the true distribution.

20%

>150

SHIA OTHER MUSLIM CHRISTIAN

Complete primary

84%

SUNNI

11%

Higher than secondary

Religion

21%

SALARIED EMPLOYEE - PRIVATE

100-150

80-100

30-50

15-30

45-54

35-44

12% 6%

Education

PETTY TRADER/SELF-EMPLOYED

UNEMPLOYED/RETIRED/HOUSEWIFE

25-34

BOYS

2% <25

GIRLS

20%

50-80

23%

43%

32% 27%

Child gender 57%

Thousand PKR

51%

10-15

MALE

<10

FEMALE

>65

34%

55-64

66%

Income Median 30-50 Thousand PKR/month

5% 2%

HINDU

OTHER

NONE

S A M P L E

C O M P O S I T I O N

S U M M A RY

S TAT I S T I C S

PA K I S TA N

Health & vaccine profile: The majority of the sample is vaccinated against COVID-19 and accepts childhood vaccines for their children – while the HPV awareness is low, as expected PA K I S TA N n = 3 7 3 4

COVID-19 vaccination

Public/private healthcare

64%

36%

PUBLIC

PRIVATE

Type of health service used for most of respondent’s health issues

16%

YES

95% YES

Whether respondent has heard about the HPV vaccine

Child vaccination

HPV vaccination

57%

DOCTORS WITH THEIR OWN OFFICE

44%

REFERRAL HOSPITALS

38%

LOCAL HOSPITALS

LADY HEALTH WORKER

84%

Vaccination status of respondent

Type of provider

LOCAL HEALTH CLINIC

HPV vaccine awareness

17% 15%

91%

YES

N/A

Whether child has received at least one dose of measles, hepatitis B, yellow fewer, or tuberculosis vaccine

Type of healthcare provider used for most of respondent’s health issues (multiple choice) – top 5 across respondents 48

S A M P L E

C O M P O S I T I O N

S U M M A RY

S TAT I S T I C S

Geographically, the sample ensures representation across Kenya and Pakistan, including hard-to-reach populations in the North Eastern Kenyan region and Baluchistan in Pakistan PA K I S TA N

K E N YA

G I L G I T

R I F T

VA L L E Y

E A S T E R N N O R T H

298

461 514

156

K B Y B E R

688

E A S T E R N

W E S T E R N

B A L T I S T A N

869

P A K H T U N K W H A

119

A Z A D &

417

J A M M U

K A S H M I R

153

C E N T R A L N YA N Z A

369 352

P U N J A B

1697

N A I R O B I

B A L U C H I S T A N

C O A S T

S I N D H

178

978

Original strategies for the worlds of tomorrow