Understanding and explaining the link between anthroposophy and vaccine hesitancy: a systematic review.

BACKGROUND: Due to low vaccination uptake and measles outbreaks across Europe, public health authorities have paid increasing attention to anthroposophic communities. Public media outlets have further described these communities as vaccine refusers or "anti-vaxxers". The aim of this review was to understand the scope of the problem and explore assumptions about vaccination beliefs in anthroposophic communities. For the purpose of this review, we define anthroposophic communities as people following some/certain views more or less loosely connected to the philosophies of anthroposophy. The systematic review addresses three research questions and (1) collates evidence documenting outbreaks linked to anthroposophic communities, (2) literature on vaccination coverage in anthroposophic communities, and (3) lastly describes literature that summarizes theories and factors influencing vaccine decision-making in anthroposophic communities. METHODS: This is a systematic review using the following databases: Medline, Web of Science, Psycinfo, and CINAHL. Double-blinded article screening was conducted by two researchers. Data was summarized to address the research questions. For the qualitative research question the data was analysed using thematic analysis with the assistance of Nvivo12.0. RESULTS: There were 12 articles documenting 18 measles outbreaks linked to anthroposophic communities between the years 2000 and 2012. Seven articles describe lower vaccination uptake in anthroposophic communities than in other communities, although one article describes that vaccination coverage in low-income communities with a migrant background was lower than in the anthroposophic community they studied. We found eight articles examining factors and theories influencing vaccine decision making in anthroposophic communities. The qualitative analysis revealed four common themes. Firstly, there was a very broad spectrum of vaccine beliefs among the anthroposophic communities. Secondly, there was a consistent narrative about problems or concerns with vaccines, including toxicity and lack of trust in the system. Thirdly, there was a strong notion of the importance of making individual and well-informed choices as opposed to simply following the masses. Lastly, making vaccine choices different from public health guidelines was highly stigmatized by those outside of the anthroposophic community but also those within the community. CONCLUSION: Continuing to further knowledge of vaccine beliefs in anthroposophic communities is particularly important in view of increasing measles rates and potential sudden reliance on vaccines for emerging diseases. However, popular assumptions about vaccine beliefs in anthroposophic communities are challenged by the data presented in this systematic review.

Sexual and reproductive healthcare utilisation and affordability for South Sudanese refugees and host populations in Northern Uganda: A mixed methods study.

Given Uganda's increasing refugee population, the health financing burden on refugee and host populations is likely to increase because Uganda's integrated health system caters to both populations. We used sexual, reproductive, and maternal health (SRMH) as a lens to assess the utilisation and user cost of health services in Northern Uganda to identify potential gaps in SRMH services and their financing. We conducted a cross-sectional survey among 2,533 refugee and host women and girls in Arua and Kiryandongo districts. We conducted 35 focus group discussions and 131 in-depth interviews with host and South Sudanese refugees, community members, health workers, NGO and governmental actors. Qualitative data were analysed thematically using a framework approach. Quantitative data were analysed using t-test, chi-square tests, multivariate logistical regression, and a two-part model. We found high levels of access to maternal care services among refugee and host communities in Northern Uganda, but lower levels of met need for family planning (FP). Refugees had higher uptake of delivery care than host communities due to better-resourced refugee facilities, but incurred higher costs for delivery kits and food and less for transport due to facilities being closer. FP uptake was low for both groups due to perceived risks, cultural and religious beliefs, and lack of agency for most women. Host communities lack access to essential maternal healthcare services relative to refugees, especially for delivery care. Greater investment is needed to increase the number of host facilities, improve the quality of SRMH services provided, and further enhance delivery care access among host communities. Ongoing funding of delivery kits across all communities is needed and new financing mechanisms should be developed to support non-medical costs for deliveries, which our study found to be substantial in our study. All populations must be engaged in co-designing improved strategies to meet their FP needs.

Integrated care: learning between high-income, and low- and middle-income country health systems.

Over the past decade, discussion of integrated care has become more widespread and prominent in both high- and low-income health care systems (LMICs). The trend reflects the mismatch between an increasing burden of chronic disease and local health care systems which are still largely focused on hospital-based treatment of individual clinical episodes and also the long-standing proliferation of vertical donor-funded disease-specific programmes in LMICs which have disrupted horizontal, or integrated, care. Integration is a challenging concept to define, in part because of its multiple dimensions and varied scope: from integrated clinical care for individual patients to broader systems integration-or linkage-involving a wide range of interconnected services (e.g. social services and health care). In this commentary, we compare integrated care in high- and lower-income countries. Although contexts may differ significantly between these settings, there are many common features of how integration has been understood and common challenges in its implementation. We discuss the different approaches to, scope of, and impacts of, integration including barriers and facilitators to the processes of implementation. With the burden of disease becoming more alike across settings, we consider what gains there could be from comparative learning between these settings which have constituted two separate strands of research until now.

Measuring the health systems impact of disease control programmes: a critical reflection on the WHO building blocks framework.

BACKGROUND: The WHO health systems Building Blocks framework has become ubiquitous in health systems research. However, it was not developed as a research instrument, but rather to facilitate investments of resources in health systems. In this paper, we reflect on the advantages and limitations of using the framework in applied research, as experienced in three empirical vaccine studies we have undertaken. DISCUSSION: We argue that while the Building Blocks framework is valuable because of its simplicity and ability to provide a common language for researchers, it is not suitable for analysing dynamic, complex and inter-linked systems impacts. In our three studies, we found that the mechanical segmentation of effects by the WHO building blocks, without recognition of their interactions, hindered the understanding of impacts on systems as a whole. Other important limitations were the artificial equal weight given to each building block and the challenge in capturing longer term effects and opportunity costs. Another criticism is not of the framework per se, but rather how it is typically used, with a focus on the six building blocks to the neglect of the dynamic process and outcome aspects of health systems.We believe the framework would be improved by making three amendments: integrating the missing "demand" component; incorporating an overarching, holistic health systems viewpoint and including scope for interactions between components. If researchers choose to use the Building Blocks framework, we recommend that it be adapted to the specific study question and context, with formative research and piloting conducted in order to inform this adaptation. SUMMARY: As with frameworks in general, the WHO Building Blocks framework is valuable because it creates a common language and shared understanding. However, for applied research, it falls short of what is needed to holistically evaluate the impact of specific interventions on health systems. We propose that if researchers use the framework, it should be adapted and made context-specific.