Examining Enablers of Vaccine Hesitancy toward Routine Childhood and Adolescent Vaccination in Malawi

"...understanding nuances of vaccination acceptance or vaccine demand insights and the underlining drivers in resource-low settings such as...Malawi, where there had been dearth of evidence-based findings for policy actions."

Vaccine hesitancy is one reason for difficulties with maximising vaccination uptake in Malawi. Much of the evidence around hesitancy has been focused on high-income settings, and little is known about the extent of and reasons for hesitancy in lower-income settings. The drivers can be different when introducing new vaccines such as those against human papillomavirus (HPV) or COVID-19. Thus, this study explored factors from multiple perspectives that influence hesitancy among caregivers of children and adolescent girls eligible for childhood routine immunisation (RI) and the HPV vaccine in Malawi.

The study was conducted between April to May 2020 in one district with high vaccine coverage (Lilongwe), one with low vaccine coverage (Dowa), and one each in an urban (Zomba) and rural (Salima) district where the HPV vaccine had been implemented. The study considered it vital to collect opinions from both the demand side (community members, including caregivers, community and religious leaders, etc.) and supply side (such as healthcare workers, national and district-level officials of the Expanded Program on Immunisation (EPI), etc.), to enable comprehensive understanding of the phenomenon (hesitancy). There were 25 key informant interviews and two focus group discussions with 13 participants.

The World Health Organization (WHO) Strategic Advisory Working Group (SAGE) vaccine hesitancy model/matrix was used to organise factors driving vaccine hesitancy. The model identifies 3 dimensions of vaccine-hesitancy determinants: vaccine/vaccination-specific issues, individual and group influences, and contextual influences. See Figure 2 in the paper for a summary of the results, based on the WHO SAGE model.

The study found that most factors driving vaccine hesitancy for RI were also relevant for the HPV vaccine. Shared drivers included: inadequate knowledge of immunisation, poor awareness of the vaccination schedule, low literacy levels of caregivers, lack of confidence in safety/effectiveness of vaccines, religious beliefs (e.g., among the Zion and Apostolic faith sects), inadequate resources at clinics that discourage caregivers, distance and transport to the vaccination clinic, complacency (low risk perception), disconnect between the healthcare system and community gatekeepers/leaders (essential stakeholders not consulted by the EPI), and gender roles in vaccination decision-making ("Well, even though we know the importance of immunisation, our husbands must still agree before we can carry our children to hospital").

HPV vaccine hesitancy seemed particularly impacted by misconceptions, rumours, and conspiracy theories. For instance, participants reported a misconception that once their daughters get HPV vaccine, they become infertile or have reduced libido. Other caregivers expressed suspicion as to why the HPV vaccine was being offered only to girls. RI hesitancy, specifically, seemed to be driven by competing or poorly scheduled healthcare services: Participants alluded to missed appointments resulting in incomplete immunisation when all the immunisation services were not centralised in one spot or operated on different schedules.

Overall, however, most participants acknowledged that caregivers typically wish for their children to be immunised against vaccine-preventable diseases and agreed that vaccination is a vital topic within households. The findings reflected the relatively high national uptake for routine childhood immunisations in Malawi, as compared to other parts of sub-Saharan Africa, and indicated that while there is clearly some hesitancy in Malawi, it has not yet translated into widespread declines in childhood vaccination uptake.

In terms of action to be taken based on these results, the researchers note that demand for vaccination requires a general perception that vaccines are safe and effective, thereby increasing the feeling they protect one from serious illness. Thus, immunisation campaigns need to be perceived to be of good quality and have vibrant local engagement. Given the conservative nature of the setting and the findings about gender norms in decision-making, fathers or husbands are a group that should be given significant priority in educational and advocacy strategies.

The findings here also reflect previous studies across Africa suggesting that residents with low adult literacy have lower acceptance of vaccination. Low levels of literacy influence the understanding of public health messaging, and so written vaccination messaging directed at communities with low literacy levels should be designed using pictures or symbols that are easy to comprehend. In this regard, the researchers urge an overhaul of the immunisation communication system and educational programme of the EPI, which has often focused on urban (high-literacy area) compared to rural (low-literacy area) settings. Future campaigns should fully consider rural and remote settings in the production, planning, and dissemination of immunisation knowledge or information, including consideration of local languages or dialects.

Communication with local "gatekeepers" (e.g., community and religious leaders) is also critical when building and strengthening cooperation for any public health effort in Malawi. Such strategic engagement boosts local confidence in healthcare services, including vaccination. For instance, some misconceptions about the HPV vaccine can be corrected by religious leaders.

Another suggestion is to integrate a short messaging service (SMS) reminder system in order to address vaccination scheduling problems identified among caregivers (i.e., for those who have mobile devices).

Based on the findings of this study, the researchers urge that strategies developed to address vaccine hesitancy must be multi-component and wide-ranging. For the introduction of new COVID-19 vaccines, the following will be especially important: considering the literacy level of the population and creating communication campaigns that are sensitive to local settings; ensuring that messaging on safety and vaccine effectiveness is driven by gatekeepers and religious leaders, especially from the most sceptical Christian sects; and dealing with low risk perception and conspiracy theories inspired by rumours and misinformation by using local celebrities or credible community gatekeepers.

In conclusion, the evidence presented here, and the lessons learned from the rollout of new vaccines, such as HPV, "can provide a starting point for tailored public health messaging...specific to the Malawi population. This has implications both for current levels of vaccine acceptance and the introduction of any new vaccine....A proactive and coordinated approach to health promotion will be vital in ensuring high levels of acceptance and increased uptake."