Anthropology Archive

Active Demand Passive ACCEPTANCE

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Apart from structural barriers, health belief studies also aim at identifying and finding solutions to cultural barriers to vaccination acceptance. Acceptance of vaccinations can, according to Nichter (1995), be differentiated into active demand and passive acceptance. Active demand "entails adherence to vaccination programs by an informed public which perceives the benefits of and need for specific vaccinations. Passive acceptance denotes compliance: passive acceptance of vaccinations by a public which yields to the recommendations and social

pressure, if not prodding, of health workers and community leaders" (Nichter, 1995, p.617). Others (Streefland et al., 1999) have suggested that such a dichotomy is not sensitive enough to variations in actual vaccination behavior. Acceptance, it is argued, can be more or less active. Despite efforts to deliver vaccines virtually to every child's doorstep worldwide, empirical studies suggest that mothers have to overcome substantial barriers to get their children vaccinated. As mentioned above, they have to walk far, or wait for a long time before being attended to. Is such acceptance passive? Or is it active demand?

Insight into vaccination acceptance and demand requires an understanding of local notions of disease etiology. Very few studies have explored these in relation to interpretations of vaccine efficacy, reflecting perhaps a neglect in medical anthropology for preventive medicine. Many more studies have been done on indigenous notions of therapeutic medicine (Van der Geest, Reynolds, Whyte, & Hardon, 1996). In their study among the Bambara of Mali, Imperato and Traore (1969) point out that the Bambara perceived a vaccination to be an amulet that works if Koranic charms and diviners' incantations have failed. Just as amulets need to be renewed, so vaccinations are seen to be timebound. In Indonesia mothers who do not fully vaccinate their children were found to believe that their children are healthy, and therefore not in need of further vaccinations (Nichter, 1995). In the view of the mothers it was the quantity, and not the quality of the distinct vaccinations that mattered. And, Mull, Anderson, and Mull (1990) describe how in the Hindu Kush region of Pakistan, tetanus-toxoid (TT) vaccines given to mothers are seen to prevent or cure Khudakan, an illness associated with neonatal tetanus. Khudakan, according to their respondents, is caused by spirits passed on from the mother to the child. One reason that TT vaccination was accepted is that it is congruent with local beliefs. Others have reported that mothers do not have faith in the power of the vaccine to prevent disease; rather they expect the vaccine to reduce the severity of the disorder (Odebiyi & Ekong, 1982).

Congruence with local notions of disease etiology and vaccine efficacy clearly affects the extent to which people accept and demand vaccines. When they believe that the vaccines have a general protective effect, and serious illness still occurs, individual mothers may decide against further vaccination of their children. Refusal to vaccinate is then based on individual weighing of costs and benefits. In the above cited case on the promotion of hepatitis B vaccine in Delhi as protection against pilia (jaundice), the authors note that medically, jaundice can be caused by different types of hepatitis. Hepatitis A is common in the community and this vaccine does not protect against it. The authors argue that a future problem for the hepatitis B immunization program is that it will in fact not prevent jaundice from occurring. If a child, despite having been vaccinated, falls ill with pilia (caused by hepatitis A) then the mother's faith in the immunization program may be shattered (Addlakha & Grover, 2000).