Understanding Factors Influencing Polio Vaccine Uptake in Ghana - Developing Meaningful Community Mobilization and Engagement Strategies in Collaboration with Religious Leaders

"The study aligns with GPEI [Global Polio Eradication Initiative] strategies to undertake evidence-based polio vaccine promotion and to place human behavior in the center to fight polio..."

Although Ghana has not experienced circulating vaccine-derived poliovirus 2 (cVDPV2) outbreaks since 2021, the country remains vulnerable to reinfection and accordingly must continue initiatives to create vaccine demand. Knowledge about vaccination is rarely a trigger for changing behaviours. Instead, behaviour is influenced by various psychological, social, and environmental factors that must be understood in a given context. This study follows human-centred approaches by engaging religious leaders in vaccine demand creation. The findings will inform the development of strategies and interventions on how to support Ghanaian religious leaders' efforts to conduct polio vaccine demand activities within their communities.

This study follows the Behavioural Drivers Model (see Related Summaries, below). In that vein, a semi-structured question guide for focus group discussions (FGDs) was developed that included questions covering psychological, social, and environmental factors. The questions were discussed with a number of experts, piloted, and adjusted accordingly. The FGDs were conducted by 4 Ghanaian research team members with experience both in collecting qualitative data and in discussing various issues with religious leaders.

The sample included 20 religious leaders from 11 of the 16 regions of Ghana. They included 10 Christian religious leaders, 8 Islamic religious leaders, and one male and one female who were leaders in African traditional religions. Twelve of the 20 were 41-60 years old, with the remaining either over age 61 or 21-40 years old. Seven of the 20 participants came from rural areas.

The article outlines the factors influencing uptake of the polio vaccine, as shared by the FGD participants. For example:

• Perceptions of polio: Most respondents believed that people in their communities had heard of polio. However, they believed that people had different understandings about the causes of polio.
• Perceived efficacy of the polio vaccine: Many respondents highlighted that community members had doubts about the ability of the vaccine to prevent children from getting polio. They cited having witnessed polio among vaccinated children or having heard of such cases in the community.
• The perceived safety of the polio vaccine: Most respondents believed that community members had doubts about the safety of the polio vaccine.
• Indifferent attitude of parents toward the polio vaccine: Respondents highlighted that not all parents consider the polio vaccine important, and, accordingly, they do not necessarily give all the doses of the vaccine to their children.
• Mistrust toward modern health systems: Some respondents explained that people who use traditional healers, especially those who use traditional birth attendants, usually do not believe in immunisation.
• Religious beliefs: Some respondents explained that there were some faith-based groups that believed only in the healing power of God and disregarded modern medicines, including vaccines, as a means to protect one from disease.
• Personal characteristics of those more likely to accept or reject the polio vaccine: Several respondents pointed out that educated people were more likely to take the vaccine in their communities because they had more information about the benefits of the vaccine. They also noted that women were often better informed than men about child health because they receive information on polio and polio immunisation at the health centres.

Thus, the study shows that both religious leaders and community members in Ghana are confused about the causes and the severity of polio infection, as well as about the polio vaccine. This central finding highlights the need to provide high-quality information to religious leaders and to shed light on how they can deliver this information to community members. Options include:

• Lessons learned from the Polio Communication Network (PCN), which was established to respond to the polio outbreaks in Horn of Africa, could be used in Ghana by involving religious leaders in microplanning how information can be shared at the community level and the type of information needed to curb information voids. Such voids are likely to increase mistrust toward the vaccine and vaccination programme and increase the spread of misinformation.
• Religious leaders require capacity building on how to better identify and manage misinformation with some basic techniques such as debunking and prebunking. They also need capacity building on how to respond to emotional narratives that may include techniques such as the use of therapeutic storytelling. It could also be worthwhile to familiarise community leaders with the basics of social and behavioural communication (SBCC), including the cognitive biases that are likely to influence community members' acceptance of polio efficacy and safety-related messaging.
• Religious leaders can learn to use specific communication frameworks to manage cultural and religious concepts that people link with polio and the vaccine such as LEARN, which is a process including listening, explaining, acknowledging, recommending, and negotiating that builds on culturally competent communication.
• Religious leaders can be used as catalysts for changing community norms (e.g., parental indifference) regarding the polio vaccine by focusing efforts on positive behaviour change towards the vaccine. Engaging community leaders and community members jointly to identify motivational factors that are culture and context specific could facilitate the design of motivational strategies and tools that can be used in vaccine demand generation.

In addition, community outreach activities could focus on educated women in urban areas, who are believed to be more likely to accept the polio vaccine than others, and engage them as champions and role models for polio vaccine demand generation. These champions could in turn focus their efforts on those who are more reluctant to take the vaccine, drawing on community leaders' in-depth understanding about the reasons for people's reluctance and developing targeted and personalised messages to address them.

To recap, the study resulted in a set of recommendations to support religious leaders in polio vaccine demand creation. They include: providing high-quality information and tools to convey this information to community members, developing tools to communicate biomedical information to people with culturally and religiously diverse illness explanations, building capacity to identify and manage misinformation, strengthening communication skills and tools to address emotional narratives, building a basic understanding of SBCC, and enhancing positive attitudes of religious leaders toward polio vaccines so they can act as a catalyst for social norm change around polio vaccines in their communities.

In conclusion: "Overall, it is important that religious leaders are given an opportunity to consider various cultural and traditional aspects to determine appropriate vaccine demand creation strategies and messages to use when creating polio vaccine demand in their communities."