Underlying issues are key to dispelling vaccine doubts.

Why is the same vaccine accepted in one part of the world and rejected in another? Heidi Larson tells Fiona Fleck why communicating the benefits versus the risks of vaccination is just part of the battle to gain public confidence in vaccines. Q: How did you become interested in the public response to vaccines? A: When I was leading communications for global immunization at UNICEF and chairing the advocacy taskforce for GAVI, the focus of my work was initially strategic communication, but I ended up spending more time than expected going out to countries that were facing challenges with vaccine acceptance. Most acute was the boycott of the polio vaccine in northern Nigeria 10 years ago, but there were other instances never reported by the media in which communities--and even governments--questioned certain vaccines. As an anthropologist, my job is to understand the social, cultural or political drivers of health behaviours--such as vaccine reluctance or rejection surrounding vaccination--and then to sit down with local vaccination teams and representatives from health ministries to discuss how best to communicate the need for the vaccine and, where necessary, strategies to prevent too much of a. drop in vaccine acceptance. Q: Would you agree with the assessment of the recent Report of the International Monitoring Board (IMB) of the Global Polio Eradication Initiative last year that the campaign requires more focus on communications? A: Communications can't fix a problem you don't understand. I had a sign saying this on my desk at UNICEF, because people tend to think that when there is a lack of public acceptance of a vaccine, you just need to explain the risks and the benefits to them. But sometimes the lack of confidence in vaccines is not just about communicating more effectively, but about delivery issues or different belief systems or, for example in the case of polio, needing security and diplomacy strategies, which the IMB also recognizes. O: How can medical anthropologists help? A: As anthropologists, we seek to understand what drives human behaviour and the method of study we most commonly use is "participant observation", that is embedding yourself in the community often during the course of field work. Sometimes it's about paying attention to small details that can reveal the underlying issues that are generating concerns. Q: For example? A: Before the polio vaccine boycott in northern Nigeria, we already saw pockets of resistance to the oral polio vaccine in Uttar Pradesh in northern India, although there was never a statewide political boycott. Rumours were circulating in the Indian state that vaccines sterilize recipients, but when we sat down and talked with the women from these communities, we found that their concerns were different. They didn't want their children to be vaccinated by people from Delhi or other places outside their region because if there was a problem they wouldn't know who to turn to and they didn't want their children vaccinated by men. You can have all the communications in the world about the vaccine safety, but these will never change such concerns and, ultimately, people's behaviour. When you launch a vaccination campaign, communities already have their own approach to health care and we need to understand this because, in a sense, we are trying to displace it. Q: How did you get involved in the SAGE Working Group on Vaccine Hesitancy? A: The group was formed in 2012. It's a positive step in response to an issue that has been brewing over the last decade. The biggest game changer was the polio vaccination boycott in northern Nigeria in 2003. After that, more serious consideration was given in the public health community to what had been thought of as marginal and alternative views on vaccination. Q: What is the significance of the new SAGE working group? A: There used to be a polarized view that people were either pro- or anti-vaccine. …