Parental Concerns and Uptake of Childhood Vaccines in Rural Tanzania - A Mixed Methods Study

"While increasing exposure to vaccines has resulted in greater awareness and dialog around vaccines in Tanzania, there may be insufficient emphasis on studying and mitigating the emergence or persistence of parental concerns."

Of the countries in Sub-Saharan Africa (SSA), Tanzania, under the leadership of the national Immunization and Vaccine Development (IVD) programme, has one of the highest rates of coverage of routine childhood vaccines. Even so, 1 in 4 children is that country is not fully vaccinated. To inform the development of interventions to reduce vaccine hesitancy and improve uptake of basic childhood vaccinations, this study used a mixed methods approach to describe and contextualise parental concerns towards vaccines in southern Tanzania.

Between 2016 and 2017, the researchers conducted a cross-sectional survey (n = 134) and 4 focus group discussions (FGDs, n = 38) with mothers of children under 2 years of age residing in either 1 urban district (Mtwara Municipality) or 1 rural district (Mtwara District Council) in Mtwara Region in Southeastern Tanzania.

Although vaccine coverage and timeliness were similar between rural and urban settings, rates varied widely by vaccine. Vaccination coverage was lowest for the oral polio vaccine (OPV1 and OPV3, 65.6%; OPV2, 68%) and highest for the birth dose of the Bacillus Calmette Guerin vaccine (BCG0, 92.8%) and the second dose of the pentavalent vaccine (Penta2, 92.8%). With the exception of BCG0, timeliness of vaccinations was low for all vaccines.

A majority of the mothers (72%, n = 96) participating in the survey self-reported that their child did not receive vaccine(s) they were supposed to get, citing the unavailability of vaccines (n = 42, 44%) and being asked to return at another time by clinic staff (n = 35, 36%). Other reasons included maternal or child sickness, travel, and forgetfulness. Reasons related to complacency or vaccine confidence were mentioned, but with very low frequencies. A few women thought vaccines were not needed (n = 4) or not effective (n = 1), had had a bad experience with previous vaccination (n = 1), or had a family member or friend who advised against it (n = 1).

Table 2 in the paper shows the results of 4 models of vaccine hesitancy:

• Model 1 describes the mean difference in hesitancy between rural and urban mothers: Rural residence was associated with significantly higher vaccine hesitancy.
• Model 2 ("Information model") adds variables indicative of access to information, which is conceptually related to the confidence and complacency domains of the 3C's model: Literacy and media exposure, but not formal education, were negatively associated with vaccine hesitancy.
• In Model 3 ("Access model"), variables related to physical access and household economic wellbeing, which are related to the convenience domain of the 3C's model, were not associated with vaccine hesitancy.
• Model 4 includes the full set of covariates: Only literacy and media exposure were significantly associated with vaccine hesitancy.

On average, urban women had a lower vaccine hesitancy score compared to rural women. However, in Models 2-4, after controlling for demographic, information, access, and/or other characteristics, the difference in vaccine hesitancy between rural and urban mothers was no longer statistically significant at conventional levels.

Mothers participating in FGDs indicated high perceived risk of vaccine-preventable illnesses, but they expressed concerns related to poor geographic accessibility, unreliability of services, and missed opportunities for vaccinations resulting from provider efforts to minimise vaccine wastage. Per the researchers, "service unavailability or refusal could contribute to reduced trust, perceived unreliability of the health system, and decreased convenience of accessing vaccines." Some women in the focus groups referred to others in the community who lacked knowledge about vaccines or knowledge of its importance, and suggested a role for healthcare providers in educating them.

Reflecting on the findings, and on a communication front, the researchers point to results from the cross-sectional survey indicating that access to information may be a key driver of differences between rural and urban areas. Another finding is that higher literacy and media exposure are associated with lower vaccine hesitancy. They cite a study of community vaccine perceptions suggesting that health promotion, community sensitisation, and efforts to improve provider-patient relationships are potential strategies for increasing vaccination coverage among rural Tanzanian children.

Also, in light of the agreement on the part of FGD participants on the key role of mothers in healthcare decisions related to their child, the researchers note that male involvement in maternal and child health services has been found in other studies to improve uptake of preventive health behaviours. They say that, in the context of vaccinations, male involvement may help reduce delays in instances where the mother is unable to bring the child to the health facility. "Further investigations of paternal perceptions towards vaccines and factors influencing their participation in child health services are important to understand the household dynamics surrounding vaccination decision-making and access of vaccination services."

The researchers indicate that the study findings were shared with representatives of the national IVD programme, and a community-health-worker-delivered intervention for improving vaccination knowledge and beliefs is being piloted in Mtwara Region.

In conclusion: "The findings of this study support existing literature on low timely vaccine coverage in children from Southeastern Tanzania...and describe an underlying, unaddressed, current of vaccine hesitancy....Further studies are needed to examine reasons for higher vaccine hesitancy among rural mothers and develop interventions to reduce these concerns. Tailored behavior change strategies for implementation within routine immunization services may hold potential to improve the timeliness of childhood vaccinations in Tanzania."