Point-of-Care Vaccinators' Perceptions of Vaccine Hesitancy Drivers: A Qualitative Study from the Cape Metropolitan District, South Africa

"South Africa is not spared the challenge of vaccine hesitancy, though its full extent and reach is yet to be fully documented."

Vaccine hesitancy is a global issue. The presence of anti-vaccination lobbyists on the South African web-space is an indication of the possible presence of this global threat, which may help explain the suboptimal vaccination coverage level in parts of the country such as the Western Cape Province. This study investigates vaccine hesitancy and describes point-of-care vaccinators' perceptions of the drivers of vaccine hesitancy in the Cape Metropolitan District, South Africa.

The researchers conducted in-depth interviews with 19 point-of-care vaccinators in 16 purposively selected healthcare facilities in the Cape Metro between September and November 2019.

Overall, the vaccinators perceived that the populace they serve has positive attitudes with regard to vaccination; of the 11 (59%) who did report experiencing vaccine hesitancy, most only recalled few incidents. That said, several themes were identified in this study as the major drivers of vaccine hesitancy in the Cape Metro (illustrated in the article by quotations from interviewees):

• Religion and culture: Religion was the most common reason cited for vaccine hesitancy; it was identified in members of both the Christian and Islamic religions. Participants reported encountering people from other cultures or countries that may have particular cultural, traditional, or religious beliefs that might inform and/or influence vaccination decisions. Notably, the deep-rooted, personal nature of religion as a driver of vaccine hesitancy makes it a particularly difficult challenge to confront. However, vaccine hesitancy linked to religion might be tackled through effective public awareness campaigns and early government-backed stakeholder engagement.
• Misinformation on the internet: None of the 19 participants, including those who said they had not encountered vaccine-hesitant individuals, spoke about internet-sourced information as motivating people to get vaccinated. Instead, some spoke about how such information served as a dissuading factor. Per the researchers: "Adequate measures to promote the pro-vaccination efforts and voices on relevant Web 2.0 platforms which is becoming increasingly available and easily accessible in the country, and to provide correct, scientifically-backed counter responses to the anti-vaccination propaganda are urgently required."
• Concern over causing the child pain and/or adverse effects: Intramuscular or subcutaneous vaccination causes varying levels of pain and distress for the child and the primary caregiver. In the context of such concerns, one vaccinator who observed hesitancy in the facial expressions of the primary caregivers said, "Not exactly that they refused but you can see the expression, the facial expression, they don't want to". Nevertheless, after detailed explanation of the procedure and the importance of immunisation by the vaccinator, these caregivers hesitatingly allowed their babies to be vaccinated. It has been suggested that giving parents a physiological role to play in pain management during vaccination may give the parents a sense of control and reduce their own worry.
• Natural immunity development: Sourcing information from the internet seems to play a significant role in the belief that the child should build up his or her own immunity, as mothers who refuse vaccination on this grounds frequently refer to the internet.
• Literacy levels of the primary caregiver(s): One participant opined that illiteracy is a cause of vaccine hesitancy, while two separate participants mentioned fellow healthcare professionals who had some form of tertiary education yet were themselves vaccine hesitant. Vaccine hesitancy was formerly associated with low literacy levels, but a shift has been observed in recent years to the converse, and the current study's findings align with that trend.

The findings of this study shows that the drivers of vaccine hesitancy as perceived by the participating point-of-care vaccinators can be viewed as happening on three broad levels: (i) the individual level, which covers the themes of internet misinformation and literacy levels; (ii) the social/contextual level, which covers the theme of religion and other cultural orientations that complicate individuals' and families' willingness to get vaccinated; and (iii) the broad level of vaccine/vaccination administration, which covers the themes of concern over the child's pain/adverse events following immunisation (AEFIs) and preference for natural immunity development.

The study found drivers of vaccine hesitancy that have been previously identified in other parts of the world, notably in high-income countries. This fact suggests that the interventions that have found to be effective in high-income settings could be explored in low- and middle-income countries (LMICs), such as the one in which this study was conducted. Suggested strategies include health education in the communities and stakeholder engagement, as well as insightful and informative discussions in the clinics - as suggested by the point-of-care vaccinators in the Cape Metro.