'When You Welcome Well, You Vaccinate Well': A Qualitative Study on Improving Vaccination Coverage in Urban Settings in Conakry, Republic of Guinea

"Community involvement is a key factor for vaccine acceptance and should therefore be allocated sufficient resourcing and prioritization in the preparation of future campaigns."

Recurrent measles epidemics have occurred in Guinea since 2014. To respond to one such outbreak, in April 2017, Médecins Sans Frontières (MSF) supported the Ministry of Health in conducting a mass vaccination campaign (MVC) in Conakry, Guinea. During the MVC, the main reasons for non-vaccination were lack of knowledge (51%) followed by lack of opportunity (42%). In light of suboptimal vaccine uptake during this MCV, the researchers sought a more detailed, qualitative analysis of these reasons in order to adapt strategies to improve future coverage. The specific objectives were to explore caregivers', health professionals', and community leaders' perceptions of vaccines and to understand their experiences and challenges.

In 2 urban communes in Conakry, the researchers conducted 9 focus group discussions (FGDs) with caregivers (n=68), the majority of whom were Muslim, and 13 key informant interviews (n=13) with religious and community leaders, health professionals, and community health workers (CHWs) involved in the preparation and implementation of the April 2017 MVC. CHWs in Guinea are community members who deliver sensitisation messages and logistical details about vaccination during MCVs.

Vaccinations were widely regarded positively and their preventive benefits noted. Imams described how disease prevention is aligned to the teachings of the Quran and detailed their role in translating this message to the communities with whom they work. However, several issues were identified that influenced caregivers' decisions on whether to vaccine or not. Vaccine side effects and the subsequent cost of treatment were commonly reported concerns. Several caregivers also noted their insufficient knowledge of vaccines. Three key knowledge gaps emerged that limited caregivers' trust in vaccines: (i) side effects of vaccines, (ii) associated costs of treating the side effects and (iii) negative perceptions of the health system, particularly in a post-Ebola period. Caregivers believed improved knowledge could improve uptake in future campaigns. Key informants stressed the importance of ensuring that CHWs had enough knowledge and proficiency to explain to local community members the potential side effects of vaccines.

All health professionals and the majority of caregivers said CHWs should be locally recruited to ensure they had in-depth knowledge and experience of the communities. Caregivers identified that this included language competencies in order to properly communicate with intended populations. Familiarity with the neighbourhoods and the local communities was believed to increase trust in the vaccination campaign and related activities. Specific examples included the need for extending an appropriate greeting and introduction, speaking politely, and being suitably dressed. Without adequate attention to these components, caregivers described their reluctance or refusal to vaccinate.

Key informants made numerous references to "religion" and "illiteracy" of the communities as reasons for low vaccine uptake, factors that were not supported during the discussions with caregivers.

In short, against a background of general lack of trust in the healthcare system, suggestions for improving uptake in future MCVs in Guinea include:

• Strengthen CHWs' knowledge, attitude, and skills, and ensure they are recruited from the community based on their knowledge of the community, their competencies, and their ability to communicate.
• Improve the positive perception of vaccines by providing messages on the benefits and potential side effects both during and after campaigns. Continue involving key people, such as religious leaders, in disseminating such evidence-based messages.
• Guarantee appropriate surveillance and free management of side effects for national programmes and humanitarian partners supporting vaccination campaigns and routine vaccination. (The reporting of adverse events following immunisation (AEFIs) and their free treatment, along with the provision of drugs, is already part of the standard MSF vaccination strategy.)
• Provide access to reliable information and promoting discussion about the benefits and side effects of vaccines, so as to allow caregivers' concerns to be addressed in a respectful manner.

In conclusion: "Improving caregivers' knowledge of vaccines, potential side effects and their management are essential to increase MVC coverage in urban settings. Strengthening CHWs' capacities and appropriate recruitment are key to improving trust through a community involvement approach."