Factors Affecting Vaccination Demand in Indonesia: A Secondary Analysis and Multimethods National Assessment

"...findings suggest that conventional assessments of risk profiles may need to be revisited to better account for the potential contribution and episodic nature of vaccine hesitancy."

While many strategies to counter vaccination hesitancy primarily target individuals' knowledge, awareness, and attitudes, there is less evidence on the role of community or population-based contributors. Despite efforts to increase vaccine uptake in Indonesia, coverage achieved during the 2018 national campaign measles-rubella (MR) was only 73%, with a wide subnational variation. To better understand the potential contributors to observed coverage gaps and the potential role of vaccine hesitancy, confidence, and uptake, these researchers conducted a multimethods assessment of qualitative and quantitative datasets collected during and immediately after the MR campaign.

With the aim of reaching over 32 million children aged between 9 months and 15 years old, the ambitious campaign took place in 28 of the country's 34 provinces, representing some of the archipelago's most remote and diverse regions. While most districts initiated the campaign on time, early concerns emerged regarding the halal (permissible according to Islam law) status of the vaccine. Major religious groups withdrew support early after campaign onset, leading to suspensions in dozens of districts. Doubts about the vaccine spread widely through social media, many schools refused participation, and parents withheld vaccination from their children.

Quantitative data used in this assessment included daily coverage reports provided by a digital health platform, district risk profiles that indicate precampaign immunisation programme performance, and reports of campaign cessation due to vaccine hesitancy. The qualitative assessment employed three parallel national and regional studies: (i) Evaluation of the Second Phase of MR Campaign study (interviewing vaccinators and programme managers); (ii) Evaluation of Reach Every Child study (focus group discussions (FGDs) with caregivers and stakeholders and service providers); and (3) Rapid Assessment of Immunisation among Urban Poor study (interviewing stakeholders and FGDs with mothers and community health volunteers). Deductive thematic analysis examined factors for acceptance among caregivers, health providers, and programme managers.

Coverage data were reported from 6,462 health facilities across 395 districts from August 1 to December 31 2018. There was wide variation between districts (2%-100%), and 62 of 395 (16%) districts paused the campaign due to hesitancy. Indeed, close to one-third of historically well-performing districts failed to achieve 70% coverage - highlighting the outsized role of vaccine hesitancy during the campaign. Coverage among districts that never paused campaign activities due to hesitancy was significantly higher than rates for districts ever-pausing the campaign (81% vs 42%; p<0.001).

Precampaign adequacy of district immunisation programmes did not explain coverage gaps (p=0.210), but qualitative findings shed light on potential reasons. Details on enablers and barriers are shown in tables 1 and 2 of the paper, respectively, with exemplar quotations available in table 3. Overall:

• Acceptance enablers including using digital health systems (e.g., reminders and health information through SMS (text) messages), increasing caregiver knowledge and awareness (e.g., through local village health posts and maternal and child health books), making immunisation the social norm (with many caregivers and stakeholders revealing that gender and family dynamics could overpower knowledge and intention), fostering effective cross-sectoral collaboration (e.g., by involving influential leaders in the targeted community), and establishing a conducive service environment by creating positive experiences for mothers and children (e.g., midwives wearing casual attire, friendliness, movies in the waiting area).
• Barriers included misinformation diffusion on social media, halal-haram (prohibited under Islam) issues, lack of healthcare provider knowledge, negative family influences and traditions, previous poor experiences, and fear of perceived adverse events following immunisation (AEFIs).

Implications of the findings include:

• Caregivers and their families need continuous reminders about why vaccination is important. Positive perceptions by healthcare workers and caregiver engagement are essential, especially considering that doctors and midwives remain a trusted source of information in Indonesia. Observations of the lack of provider knowledge in Indonesia highlight the need for efforts to upgrade competencies through innovative and practical training for health workers. Educational videos at health services can also help disseminate information; education on common reactions and how to differentiate them from more serious AEFI should be an important component of the overall outreach strategy.
• Government efforts on increasing health service provision to reduce access barriers remain important in enabling immunisation uptake. In light of caregivers' expressed concern about indirect (e.g., transportation) costs, the researchers propose that the village health post could be the focus of vaccination services in Indonesia, taking advantage of their location close to caregivers' homes. Restricted schedules and irregular availability of village midwives as one of service points also need to be addressed. Caregivers recommended increasing the number of health workers and space, creating a more attractive environment for children, and improving the quality of care and interpersonal interactions with health workers.
• Strategies to engage diverse stakeholders in generating positive social norms around vaccination are a critical complement to health sector engagement. In the Indonesian context, both caregivers and primary healthcare staff asserted that invitations from both religious leaders and local political heads could be transformative.
• Digital reminders and health messages were found to foster greater acceptance, and it has been recommended that missed opportunities for immunisation could be reduced with ongoing social media monitoring, which facilitates the timely identification of immunisation-related concerns.

In conclusion: "challenges related to vaccine hesitancy in Indonesia are real, complex and require tailored cross-sectoral engagement. While much of the historical emphasis of immunisation planning and programmes in Indonesia has been on improving access and addressing supply-side factors, what has emerged from this assessment is the need to focus equal importance on vaccine acceptance and demand-related concerns. To respond to these issues, the Indonesian Ministry of Health has recently updated its new national immunisation strategy. The strategy calls for interventions and engagement to foster vaccine acceptance at the individual, health facility and wider community and social levels. Future monitoring and implementation research will be required to assess the effectiveness of this approach on demand-related barriers including vaccine hesitancy, and ability to overcome pervasive coverage gaps"