Caregivers' Willingness to Vaccinate Their Children against Childhood Diseases and Human Papillomavirus: A Cross-Sectional Study on Vaccine Hesitancy in Malawi

"Multi-dimensional tools and ways to measure vaccine hesitancy exist, but little is known about their validity in non-Western settings..."

In Malawi, the percentage of fully immunised children aged 12-23 months has been declining since 1992, when coverage peaked at 82%. Uptake is affected by vaccine hesitancy, which is especially important when new vaccines, such as the human papillomavirus (HPV) vaccine, are introduced into a country. For example, Malawi has seen a decline in second vaccine doses and a high incidence and mortality rate of cervical cancer, which can be prevented by HPV vaccination. Generally, because of the intended population (adolescent girls) and amplified by rumours, mistrust of HPV vaccination seems widespread in low-income settings. This study explores factors contributing to vaccine hesitancy for routine childhood immunisation and HPV in Malawi.

The study used a cross-sectional survey design involving caregivers of children under five years old and adolescent girls. The sample population was derived using three inclusion criteria: one district with low vaccine uptake (Dowa), one district with high vaccine uptake (Salima), and one district where HPV was piloted earlier (Zomba). A convenience sample of one primary and one secondary health facility was selected within each district, and participants were systematically included (n = 600).

The measures were based on 5C scale for measuring vaccine hesitancy, which includes five psychological antecedents of vaccination behaviour:

• Confidence, which is trust in the effectiveness and safety of vaccines.
• Complacency, which exists where the perceived risks of vaccine-preventable diseases (VPDs) are low, and vaccination is not deemed a necessary preventive action.
• Constraints, which are an issue when physical availability, affordability and willingness-to-pay, geographical accessibility, ability to understand (language and health literacy), and appeal of immunisation service affect uptake.
• Calculation, which refers to individuals' engagement in extensive information searching and is related to perceived vaccination and disease risks.
• Collective responsibility, which is the willingness to protect others by one’s own vaccination by means of herd immunity.

Religion, rumours, and masculinity were added to the set of items, constituting the augmented scale as "5C+":

• Religion has been found to be a factor affecting people's attitudes toward vaccine demand.
• Rumours or misinformation affect perceptions, are amplified in the age of social media, and have been found to have an impact on vaccination demand. In addition, since knowledge is associated with HPV vaccination behaviour, this variable was considered important in the assessment of vaccine hesitancy drivers in Malawi.
• Masculinity is used here to connote a husband or father's role in the household's decision to vaccinate a child. Research has found that caregivers who solely depend on their husband's approval are prone to vaccinate less if the husband does not approve.

About 82% of the respondents relied on healthcare workers for vaccination information, while 7% indicated friends and 4% family members. Other sources, such as social media (Facebook, Twitter) and places of religious worship (mosque, church), were indicated by 1% or less. When asked about the accuracy of or trust in vaccination information provided by the different sources, trust in the community and healthcare workers was high, but trust in information received from other sources was rather low.

Confidence in vaccine safety was the strongest predictor of vaccination intention, followed by the constraint of everyday stress. Stronger agreement that the topic of vaccination must be fully understood was associated with higher vaccination intentions, while items from the collective responsibility subscale did not play a role. For the complacency items, inconsistent results emerged.

Caregivers had lower confidence in vaccine safety and efficacy when they believed rumours and misinformation, such as that prayers prevent measles, and were unemployed. Visiting the doctor made the participants feel more uncomfortable if they believed in traditional religion and misinformation (i.e., that vaccination is a means to reduce the population) and if they had lower trust in healthcare workers. Confidence was higher for those who had more trust in healthcare workers. In addition, a husband's positive attitude (approval) increased childhood vaccination intention.

For HPV vaccines, those believing in traditional African religion had lower HPV knowledge compared to those who were not religious, and respondents who had completed secondary or tertiary education showed higher knowledge than those without formal education. Knowledge of HPV did not increase vaccination intention, but the need to attain a husband's approval did. Vaccination intentions were higher for those with: lower education, more trust in healthcare workers, lower complacency, and a lower tendency toward calculating the benefits and risks of vaccination. Being a young adult and unemployed increased belief in rumours, while trust in healthcare workers reduced the belief.

The researchers note that confidence in vaccine safety and effectiveness are global vaccine hesitancy phenomena, and much research has been conducted, particularly in higher-income contexts, on how to boost this factor. In low-income settings, such as Malawi, a bottom-top approach will likely be necessary as a countermeasure, since the majority of its population lives in rural areas. In addition, since the caregivers in this study trusted healthcare workers most for their vaccination information, the Expanded Program on Immunization (EPI) in Malawi should integrate local healthcare workers into the heart of vaccination education. Interventions along these lines should fit with people's value systems and cultural norms.

As outlined here, addressing vaccine hesitancy based on rumours by using health promotion campaigns to increase vaccination demand requires a well-tailored and specific communication strategy. The strategy should not only debunk rumours surrounding vaccines but also resolve vaccine safety and effectiveness concerns raised by caregivers. Using scientific research and communicating in an evidence-informed manner may inspire stakeholder dialogue by raising different voices to allow for discussions. The proposed process builds partnerships using facts and, at the same time, counters misinformation with a non-aggressive posture. Therefore, while social media use has been associated with a negative impact on public perception of vaccines and vaccinations, it also presents an opportunity to reach young vaccine misinformation spreaders using evidence.

However, although knowledge deficits arising from lack of cognitive information seem apparent in Malawi, based on the results, when knowledge is confounded by education (especially little or no formal education), improving knowledge deficits among this group is not enough. "Trust is the bedrock of vaccination acceptance. Therefore, trust must be built in and around all facets of national EPI programs, including vaccine development, distribution, policies, healthcare systems (doctors, nurses, and immunizers), and mass vaccination campaigns."

In addition, encouraging men to attend immunisation activities, such as antenatal care appointments, could be a positive step toward improving men's perceptions of vaccines in Malawi. The finding that confidence in the effectiveness of vaccines is lower among caregivers whose children are female is concerning, as these beliefs affect vaccination behaviour. The researchers stress that more needs to be done to address such gender gaps, especially in rural Malawi.

Since unemployment was found to play a significant role in vaccine hesitancy in this study, the researchers suggest that incentives be built around vaccination attendance at health facilities, in form of provision of lunch and transportation reimbursement for caregivers, besides maintaining a free vaccination programme. Incentisising unemployed caregivers could mitigate constraints and help prevent complacency and dropout.

In conclusion: "For vaccination acceptance strategies to succeed, efforts should focus first on building trust, improving vaccine confidence, and dispelling rumors associated with vaccines or vaccinations....Thus, addressing vaccine hesitancy in Malawi requires a multi-dimensional approach that involves both communication tools and devolution of management of vaccination programs to the local level, led by local healthcare workers, since trust in them is high among the population."