Overcoming Barriers to Vaccine Acceptance in the Community: Key Learning from the Experiences of 734 Frontline Health Workers

"Immunization staff from all levels of the health system became citizen scientists, active knowledge-makers drawing on their personal experience of a situation in which they successfully overcame the barriers to vaccine acceptance in the community."

This report analyses 734 case studies developed by frontline health workers who are members of the COVID-19 Peer Hub, a digital network that connects over 6,000 health professionals across system levels from 86 countries to support implementation of country COVID-19 plans of action. In November 2020, The Geneva Learning Foundation (TGLF) asked network members whose immunisation activities had been affected by the pandemic to describe and analyse a situation in which they helped an individual or a group accept or gain confidence that taking vaccines - of any type (not just COVID-19) - would protect them from disease. Country practitioners and other stakeholders can use the resultant learnings, shared in this report from TGLF and Anthrologica, to identify good practices and strategies on overcoming barriers and increasing confidence and uptake of COVID-19 vaccines.

After an introduction, the first chapter presents the methodological approach used in the study, details the data coding and extraction process, and describes the analysis framework. In developing their case studies, Scholars (case study authors) were instructed to refer to a rubric that combined instructions and guidance, reflective questions, and checklists to guide the exercise. The rubric was designed to support Scholars in telling their story, whether in English or in French. Guided by the rubric, Scholars were prompted to critically analyse aspects of the experience they described; each case study was peer-reviewed by 3 other Scholars.

The second chapter provides basic demographic information about the 734 Scholars involved in the case study exercise: 81% (n=591) of them hailed from West and Central Africa, 11% (n=80) from Eastern and Southern Africa, and 6% (n=43) from South Asia. They did their work during 4 weeks of remote collaboration months before the first doses of COVID-19 vaccine were to arrive in Ghana and Côte d'Ivoire. In 90% of the case studies (n=661), the Scholar recorded the vaccine or antigen to which their case study related. Of these, the largest number was n=283 (43%), which referred to polio vaccine; amongst these, 25 specifically referred to the oral polio vaccine (OPV).

The subsequent 6 chapters focus on the research findings and are structured according to the peer learning activity's rubric:

• Populations engaged in the case studies: Most of the individuals and communities documented in the case studies were parents, caregivers, and family members of children, and interventions were therefore directed at increasing acceptance towards vaccination for individual families directly or were targeted as part of wider community engagement strategies. Findings from a small number of case studies identified teachers as a powerful group of influencers in the community. Although no interventions addressed groups of teachers per se, cases of non-acceptance in schools were reported, and some teachers and school principals were identified as propagators of misinformation.
• Barriers to vaccine acceptance:
  • In 33% (n=244) of the case studies, conspiracy theories and mis- and disinformation related to vaccination identified as primary barriers to vaccine acceptance. The belief that vaccination was related to sterilisation was common throughout the dataset, particularly in cases from Africa. Scholars also noted that the speed at which misconceptions and mis- and disinformation circulated and escalated increased during the pandemic, particularly over social media platforms.
  • In 20% (n=70) of case studies in English, reasons cited for low levels of vaccine acceptance in the community were linked to a conflict between vaccination and religious or customary beliefs. Of these 70 case studies, 53% (n=37) were from Nigeria (accounting for 24% of cases from Nigeria and 5% of all case studies). Relatedly, social norms could pose a barrier. In case studies from customarily patriarchal societies, the perceived self-efficacy and responsibility of a woman to allow the immunisation of her child could be limited if the male head of the household did not authorise the vaccination. Such situations were frequently reported in case studies from Nigeria (specifically amongst Hausa communities in the north of the country) and in Fulani communities across West Africa.
  • Lack of information as a barrier to acceptance was only explicitly referenced in 8% (n=59) of all case studies, although evidence suggesting limited community awareness of issues related to vaccine uptake was more widely seen. Lack of information, when identified, related predominantly to poor or inadequate knowledge of the vaccine campaign, the vaccine itself, and/or the healthcare system. For example, many individuals lacked awareness of the multiple forms of administration for the polio vaccine (oral and injectable), and this fuelled feelings of mistrust. This concern was intensified in polio campaigns in countries that had already been declared "polio-free".
  • In 25% of all case studies, general mistrust was noted as a key driver of low levels of vaccine acceptance. Mistrust was directed towards governments, international actors, and health workers and was also related to issues of associated costs, the frequency of vaccine doses/campaigns (e.g., in the case of OPV), and perceived episodes of adverse events following immunisation (AEFI). Where communities had been overlooked for initiatives, government support, grants, and other welfare benefits, levels of mistrust were higher and contributed to reduced acceptance. Six case studies indicated that failure of the government to provide treated mosquito nets contributed to high levels of mistrust.
  • Case studies from across all geographical areas reported that perceived side effects of vaccination contributed to vaccination hesitancy. Circumstantial evidence related to the side effects of vaccine antigens sparked rumours and conspiracy theories and mis- and disinformation and contributed to mistrust and fear within communities. Experiences of AEFI, whether real or perceived, first-hand or based on community anecdotes, were common and frequently led to "boycotting" vaccination. Several Scholars voiced frustration when cases of AEFI had been inadequately investigated, and they were sometimes restricted in the counselling they could provide families due to the lack of definitive information about these suspected cases. Some cost-benefit messaging focused on promoting vaccination as a way to avoid future healthcare costs associated with treating illnesses such as polio and measles.
• Interventions and actions employed: Interventions centred around multiple stakeholder involvement - specifically, engagement of community, religious, and traditional leaders. The interventions also used a variety of engagement strategies, including: direct one-to-one counselling at the individual or household level; community sensitisation for larger groups; formal meetings; and organised training sessions. Many Scholars regarded traditional and religious leaders as highly influential, authoritative members of society. Efforts to involve them in whatever capacity possible were encouraged. Across the case studies, leaders were engaged in a multiple ways: as passive gatekeepers, as vaccination champions promoting sensitisation in the community, and as mediators between community and immunisation teams, actively delivering messages, debunking misconceptions, and facilitating stronger relationships. Although religious and traditional leaders were repeatedly spotlighted as reliable channels through which to gain community trust, a small number of case studies revealed that some leaders may perpetuate misinformation in the community to fit with their own agenda.
• Moving towards greater acceptance through messages and delivery: Key determinants of successful intervention implementation often emphasised tone and delivery of information, and the approach was found to be as critical to successful vaccination outcomes as the activities themselves. Examples of successful delivery strategies included high levels of personal involvement by Scholars and use of local languages, social media, and information, education, and communication (IEC) materials. Further, the use of different communication approaches was found to have a positive effect, from using pictures and videos to interpersonal displays of understanding and compassion. This enabled Scholars to navigate sensitive dynamics such as families in grief and those in vulnerable communities impacted by displacement or war.
• Risk, context, and replicability: Recruiting local leaders, influential people in the community and respected health workers to support the community-level interventions was the most frequently reported strategy for ensuring Scholars and immunisation teams would be accepted without threat. Across the case studies, the incorporation of appropriate action to address social norms, customs, language issues, social hierarchy and power dynamics was correlated with a lower perceived level of threat and a greater level of community acceptance. Many Scholars stressed that tailoring an approach to the needs of an individual or a community was fundamental. A number of case studies illustrated the negative consequences of proceeding with interventions without having taken appropriate measures into account.
• Lessons and recommendations: Suggestions can be grouped into 4 priority and interconnected areas: community inclusion and engagement; community gatekeeper involvement; teamwork and collaboration; and communication. The latter (communication) was widely identified as a specific determinant of success in reducing barriers to vaccine acceptance. Scholars discussed the importance of multi-faceted communication strategies to address misinformation and the need to embed communication within existing community engagement structures. Several Scholars suggested that collaborations should extend beyond working with local religious and community leaders and should include more comprehensive partnerships with healthcare professionals, academics, global agencies, and other organisations that support immunisation. They felt that ongoing collaboration could save time and resources while adding more positive, reliable voices to the public conversation on vaccine acceptance.

In conclusion: "It is clear from the data presented in this report that the barriers to vaccine acceptance are complex and multifaceted. Against the backdrop of global, regional and national-level guidance, investment in identifying and supporting local level solutions is urgently needed if vaccine confidence and acceptance are to grow and be sustained. This requires greater focus on the capacity of immunisation staff to adapt their practice to best fit the local context and immediate situation...The use of ethnographic case study data has highlighted forms of knowledge and experience that are less easily accessed through formal research approaches. The situations described...address contextual, social and behavioural dynamics that may not always be considered, and present real-world strategies used by Scholars to build confidence in vaccines and vaccination with the communities they serve. Further, the case studies emphasise the need for the voices of frontline immunisation staff to be heard on the global stage."

This study was funded by the Bill and Melinda Gates Foundation.

Click here in order to request a free download of the report in English (106 pages, PDF).
Click here in order to request a free download of the report in French (106 pages, PDF).