Vaccine Hesitancy among Caregivers and Association with Childhood Vaccination Timeliness in Addis Ababa, Ethiopia

"Little research has been done regarding the potential role of vaccine hesitancy in vaccination outcomes in LMICs."

A systematic review of vaccine hesitancy in low- and middle-income countries (LMICs) generally found a great deal of concern about adverse events following immunisation (AEFIs) and distrust in health systems. Ethiopia faces public health challenges in addressing low vaccination rates in light of lacking health systems infrastructure. Given the country's low vaccination coverage and untimely receipt of vaccines, it is possible that vaccine hesitancy may contribute to poor immunisation outcomes. This study quantifies timeliness, establishes the prevalence of vaccine hesitancy, and examines the impact of vaccine hesitancy on timeliness in Addis Ababa.

In 2017, the researchers surveyed 350 caregivers of children aged 3-12 months among 5 centres in Addis Ababa. The study found that 82% of these children had received all their recommended vaccines, though only 56% had received these vaccines adhering to the recommended schedule, numbers not sufficiently high to interrupt disease (with the measles requiring upwards of 94% vaccination coverage to interrupt transmission, for example). Over time, as children progress later into the immunisation schedule, a greater proportion of vaccines were received in an untimely fashion.

With regard to hesitancy:

• Almost all caregivers (99.71%) agreed or strongly agreed that "Childhood vaccines are effective","Childhood vaccines are important for my child's health”, and "Getting vaccines is a good way to protect my child from disease". About 97% of caregivers believed that the information they "received about vaccines from the government vaccine program is reliable and trustworthy", and that “having my child vaccinated is important for the health of others in the community". On the whole, caregivers overwhelmingly agreed with 7 positively-phrased vaccine hesitancy questions that affirmed certain traits of the vaccines, such as their efficacy, importance, benefits to the community, and protective qualities.
• The 3 negatively-phrased questions yielded less uniform responses, with 11.88% agreeing that "My child does not need vaccines for diseases that are no longer common". In addition, 24.93% of the surveyed respondents replied "agree" or "strongly agree" that "New vaccines carry more risks than older vaccines", and 25.66% were concerned about serious adverse effects. Of the 349 participants who answered the question, "Have you ever hesitated getting a vaccine for your child", only 12 (3.44%) replied "Yes", and only 13 (3.74%) replied they had ever refused a vaccine for their child. Of those who had hesitated or refused, 85.71% attributed their actions to fear of needles, and 14.29% to concern over side effects.

In the multivariate logistic regression, the most hesitant tertile of vaccine hesitancy led to a significant increase in odds of untimely vaccination (adjusted odds ratio (AOR) 1.94, 95% confidence interval (CI): 1.02, 3.71). Muslim and Protestant religions were both found to be significant predictors of untimely vaccination (AOR 3.01, 95% CI: 1.33, 6.82 and AOR 3.14, 95% CI 1.26, 8.03, respectively) compared to Ethiopian Orthodox religion.

The researchers suggest that this study's findings set the stage for future, more rigorous studies to broaden the scope of literature investigating the consequences of vaccine hesitancy. Two studies in Nigeria have examined how perceptions of vaccinations may impact vaccine receipt. (Nigeria is similarly positioned to Ethiopia in terms of vaccination uptake, maintaining 25% full vaccination coverage in 2013.) One of them found that vaccine hesitancy was related to oral polio vaccine (OPV) refusal and further clarified that some of the potential reasons for this negative vaccine perception and behaviour were founded in strained relationships (perceived or real) between communities and their governing agencies who administer vaccinations. The second, a qualitative study, identified attitudes, poor communication skills among health workers, and lack of motivation as affecting vaccine perceptions.

"It is important to note that vaccine hesitancy is unlikely to be the sole factor explaining untimely vaccination, and other factors, including health literacy, may play a significant role. Nearly 50% of the surveyed respondents had an elementary education or less, indicating that level of schooling and insufficient health literacy may have explained some of the hesitancy or untimeliness of vaccinations." However, they conclude that vaccine hesitancy was found to significantly influence timeliness of received vaccinations, providing a potential intervention strategy to target educational campaigns around certain aspects of vaccine perceptions to mitigate hesitancy and subsequently, it is hoped, to improve timeliness.