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Policy and Socio-Cultural Differences Between Cantons in Switzerland

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Vaccine 37 (2019) 7539–7546 Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Policy and socio-cultural differences between cantons in Switzerland with high and low adolescent vaccination coverage for hepatitis B and HPV ⇑ Virginie Masserey Spicher , Mitchell G Weiss Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, P.O. Box, 4002 Basel, Switzerland University of Basel, P.O. Box, 4001 Basel, Switzerland article info abstract Article history: Vaccination recommendations in Switzerland are national, but vaccine coverage varies greatly from one Received 29 June 2018 canton to another, particularly for vaccinations recommended in adolescence. To explain these differ- Received in revised form 26 September ences, we studied vaccination practices and socio-cultural views from the vantage points of policy mak- 2019 ers, healthcare providers and community adolescents and parents in 4 cantons with low (LVC) and 4 Accepted 27 September 2019 cantons with high (HVC) vaccination coverage for hepatitis B (HBV) and human papillomavirus (HPV) Available online 17 October 2019 vaccines. In-depth semi-structured interviews were administered to a policy maker, a private practitioner and 4 to 7 community members (adolescents and parents of adolescents) from each of the 8 cantons. Keywords: LVCs were notable for less government involvement in vaccination issues, more autonomy of municipal- Vaccination coverage Vaccine hesitancy ities for school health, lower density of pediatricians, less information about these vaccines, greater HPV vaccine emphasis on individual rather than government responsibility for vaccinations and for anticipated com- Hepatitis B vaccine munity hesitancy. Doctors in HVCs more actively advocated for vaccines. Community views in HVCs were Adolescent health more collectivistic and reliant on schools as a source of information than in LVCs. In both groups, Health system hesitancy and concerns about efficacy were greater for HPV than for HBV vaccine. Findings suggest more School health systematic involvement of health and school authorities will be appreciated by adolescents and their parents, and will improve vaccination coverage. Interventions focused only on community awareness and hesitancy are likely to be inadequate without efforts to reach policy makers and doctors. Ó 2019 Elsevier Ltd. All rights reserved. 1. Introduction for girls younger than 15 years of age. HPV vaccination has also been recommended for boys since 2015. Although vaccination recommendations in Switzerland are Infant vaccinations are well accepted with a national coverage national [1], vaccine coverage varies greatly from one canton to of 96% at age 2 years for 3 doses against diphtheria, tetanus, another [2], particularly for vaccinations recommended in adoles- poliomyelitis, pertussis and haemophilus influenza b. Cantonal cence for hepatitis B (HBV) since 1997 and for human papillo- variations range from 90 to 99% [3]. Boosters for these vaccines mavirus (HPV) since 2007 to prevent cervical cancer [3]. HBV tend to be delayed; 4th dose coverage is 89% at age 2 and 94% at vaccination is recommended for all adolescents between 11 and age 8. Coverage for other vaccinations are lower (e.g. 87% for 15 years old with a 2-dose schedule. A 3-dose schedule for HPV measles 2 doses and 80% for pneumococcus at 2 years of age) with vaccination was initially recommended for girls 11 to 14 years wider variations across cantons (e.g. measles 81 to 95%), but stea- old, with a provision for catch-up vaccination until age 26 years. dily increasing over the years (from 71% in 2005–2007 for The 3-dose schedule was reduced in 2012 to a 2-dose schedule measles). National coverage for HBV and HPV (for girls) at age 16 reached 71% and 56% respectively in the most recent survey in 2014–2016 [3]. Abbreviations: LVC, low vaccination coverage canton; HVC, high vaccination The Swiss Federal Office of Public Health issues the national coverage canton; HBV, hepatitis B virus; HPV, human papillomavirus. ⇑ Corresponding author at: Federal Office of Public Health, Communicable vaccination recommendations, provides information material, Diseases Division, Schwarzenburgstrasse 157, 3003 Bern, Switzerland. coordinates cantonal surveys of immunization status of E-mail addresses: [email protected] (V. Masserey Spicher), children and adolescents, and publishes findings. The cantons are [email protected] (M.G Weiss). https://doi.org/10.1016/j.vaccine.2019.09.085 0264-410X/Ó 2019 Elsevier Ltd. All rights reserved. 7540 V. Masserey Spicher, M.G Weiss / Vaccine 37 (2019) 7539–7546 responsible for implementing vaccination recommendations to ents of boys. In these interviews we asked about respondents’ reduce the incidence of vaccine-preventable diseases and have background information, and the interview included questions their own implementation policies and strategies. They rely heav- about awareness, priority and practices regarding HBV and HPV ily on physicians in private practice. Many cantons also offer vaccination, and questions about structures and operations of school-based vaccinations, but the role and organization of school health systems to vaccinate children and adolescents. health systems vary greatly from one canton to another. Nationally In each of the cantons, the cantonal health authority was asked recommended vaccinations are reimbursed by mandatory health to suggest healthcare providers (private clinicians and/or school insurance. Although deductibles are not required for children up doctors) to be interviewed. Directors of educational institutions to the age of 18 years, insurance coverage requires a co-pay of a in each canton assisted in identifying adolescents aged 16 to 19 10% retention fee for treatment costs, which is capped at CHF and parents of adolescents in that age group, though not parents 350 per year for children. School-based vaccinations are generally of the adolescent respondents. These community respondents free of charge for the families. Since no vaccinations are mandated were interviewed, and vaccination records of the adolescents were in Switzerland, decisions to vaccinate are made by individuals for requested. themselves or by parents for their children. Socio-cultural differ- Interviews were conducted by VMS (who did all the policy ences across Switzerland are notable and likely to affect vaccine maker and clinician interviews as well as a portion of the inter- acceptance and demand [2]. Sceptical views of vaccinations have views of community members in French) and four female students been noted in certain areas and among certain groups of the pop- (studying public health, psychology or biomedical sciences). All ulation [4]. were trained together in a one-day workshop including role-play Vaccine hesitancy is currently a topic of interest in Europe and interviews. Interviews were done at the interviewee’s workplace, globally, often related to questions of confidence, complacency and school or home. convenience [5,6]. Acceptance of vaccines for adolescents is espe- Semi-structured interviews were recorded and transcribed. cially challenging because they are less likely to visit a doctor than Thematic analysis based on study aims and interview content younger children, and increasing autonomy may affect the was facilitated by use of MAXQDA software [9]. Data were decision-making process. Furthermore, vaccine target infections extracted from the vaccination records to assess actual vaccination are sexually transmitted, and because they manifest much later, status of the adolescents—both adolescent respondents and chil- they are unlikely to be seen by physicians who vaccinate dren of parental respondents; these data were compared with adolescents. the vaccination status reported in the interviews. Cantonal docu- To identify factors that may explain differences in vaccination ments were also used to review vaccine implementation policies coverage across cantons we examined policies, health system and strategies, with particular attention to the role of school- approaches and socio-cultural community views in low and high health. vaccine coverage cantons. Our objectives were (1) to describe the The study was approved by the Ethics Commission for North- vaccination delivery system, particularly for adolescent HBV and Western and Central Switzerland. Participants signed a consent HPV vaccinations, (2) to examine health professional and commu- form. nity vaccine awareness, priorities and practices; and (3) to com- pare low-vaccination coverage (LVC) and high-vaccination 2.3. Analytical framework coverage (HVC) cantons. The analysis of vaccination delivery systems was based on the 2. Materials and methods WHO health system building blocks framework [7,10], focusing here on health governance, health service delivery and health Our qualitative study was designed to examine in distinctively information. Analysis of the socio-cultural context was based on high- and low-coverage cantons the views of three stakeholder questions about awareness of disease and its prevention; experi- groups that collectively influence the effectiveness of vaccination ence and prior use; and priority, hesitancy and acceptance of vac- programmes: policy makers, vaccinating doctors and community cines for HBV and HPV. This framework was used for the analysis of members. The design was based on the WHO health system build- interview data from health authorities, clinicians and community
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