Towards a Further Understanding of Measles Vaccine Hesitancy in Khartoum State, Sudan: A Qualitative Study

Over the past 20 years, concerns have been raised regarding the spurious link between the measles, mumps, rubella (MMR) vaccines and development of autism and autism spectrum disorders (ASD). Such concerns have contributed to a decrease in vaccine uptake; Sudan is one of the countries that suffers from low measles vaccine coverage and from measles outbreaks. Communication strategies that address vaccine hesitancy were adopted in 2012 as a policy by the federal ministry of health in order to enhance community demand for vaccines. With the goal of facilitating the future development of interventions, this study explored the opinions of Expanded Program on Immunization (EPI) officers at ministries of health, the World Health Organization (WHO), and the United Nations Children's Fund (UNICEF), as well as vaccine care providers at primary healthcare centres.

This study was conducted in Khartoum state, where vaccination services are comparatively easily available. This allows the study of hesitancy. According to the Multiple Indicators Cluster Survey (MICS), in 2014, the percentage of children who received their first dose of measles-containing vaccine (MCV1) in Khartoum state was 89.7% and the second dose (MCV2) was 88.6%. However, the percentage of children who received full immunisation (all vaccines) in Khartoum state was 74%. Khartoum state also inhabits a diversity of groups of people in terms of socio-cultural and socio-economic backgrounds and exposure to vaccination campaigns and materials.

Qualitative data were collected using semi-structured interviews with 14 participants during the period January-March 2018. Data (i.e., quotes) were matched to the categories and the sub-categories of a framework that was developed by the WHO Strategic Advisory Group on Experts (SAGE) Working Group called 'Determinants of Vaccine Hesitancy Matrix'. It distinguishes between 3 groups of determinants: (i) contextual influences, such as religion and geographic barriers; (ii) individual and group influences, such as beliefs and attitudes about health and prevention; and (iii) vaccine or vaccination-specific influences, such as the mode of administration and the vaccination schedule.

In brief, the results indicate that the majority of participants confirmed the existence of measles vaccine hesitancy in Khartoum state. However, there was no consensus on the definition of vaccine hesitancy; thus, the researchers stress that the WHO-SAGE's definition of vaccine hesitancy needs to be better promoted among the EPI officers/experts in order to inform and improve future interventions. Other findings:

• The main contextual determinant as reported is the presence of people who can be qualified as "anti-vaccination". They mostly belong to particular ethnic/tribal and religious groups, especially the Ansar Al-Sunna group. Other groups in which vaccine hesitancy was identified include people of higher socioeconomic status and well-educated people.
• Parents' beliefs about prevention and treatment from measles are the main determinants of the group influences. Immunisation is not considered as a social norm by some people in Sudan; this was reported by one frontline provider, who explained, "A...nomad from Western Sudan...said that for us cattle are the most important (i.e. it [vaccination against measles] is not our priority)."
• The measles vaccine schedule and its mode of delivery were among the vaccine-related determinants. The researchers propose that, to address issues related to the measles vaccine schedule, a parent reminder system, including recall and text messages, could prevent parents being turned away or simply forgetting to bring the child back for the 9th and 18th month doses.

According to the researchers, further study is needed to identify refusers, their concerns, and to which groups they belong. For instance, the fatwa (religious-legal response) in Sudan about prohibiting the vaccination of children, claiming it is a conspiracy of the Jews and Freemasons, was issued in 2007 by the leader of Sudan's Muslim Brotherhood, Sadeq Abdallah bin Al-Majed. He declaimed on this topic after framing the Darfur problem as an American conspiracy. Nevertheless, there is no reported data about the implication of this fatwa on the vaccination programme in Sudan.

"To conclude, the findings of this study show how complex measles hesitancy is in Sudan and how much variation there is regarding the definition and the perceived causes and consequences. It also indicates that this risky phenomenon can only be explained (and thus possibly be intervened upon) in its specific socioeconomic and cultural context. Negative beliefs and attitudes of people (parents/guardians) are important, but vaccination program aspects should not be neglected. Therefore, developing strategies should include not only communication strategies but also programmatic interventions for improving access."