Supporting LNCT Countries in Assessing and Addressing Their Vaccine Hesitancy: Report of Interviews with In-country Stakeholders

"There is clear need for tailored tools and guidance to assist countries in assessing and addressing vaccine hesitancy issues."

Launched in 2017, the country-driven Learning Network for Countries in Transition (LNCT) is dedicated to peer learning to support countries as they transition away from Gavi support to full domestic financing of their national immunisation programmes. Recognising that addressing vaccine hesitancy is a priority in many LNCT countries, the Vaccine Confidence Project (VCP) at the London School of Hygiene & Tropical Medicine (LSHTM) and Curatio International Foundation conducted a landscape study to identify the key hesitancy challenges faced by LNCT countries and the strategies they use to address them.

Between April and June 2019, the researchers conducted in-depth interviews and focus group discussions (FGDs) with 41 immunisation experts (e.g., from Expanded Programme on Immunization (EPI), Ministry of Health, and National Immunization Technical Advisory Groups, or NITAGs) from 12 LNCT countries (Armenia, Georgia, Ghana, Indonesia, Lao PDR, Moldova, Nigeria, São Tomé and Príncipe, Sudan, Timor-Leste, Uzbekistan, and Vietnam).

Reasons for non-immunisation or delay in accepting immunisation differed across countries. However, themes emerged around confidence, complacency, and convenience:

• The most common driver of vaccine hesitancy raised across all LNCT country participants was a lack of confidence. The most prevalent concerns among parents were related to: potential side effects of vaccines reported in the media, by general practitioners (GPs), or by people they knew; trust issues around new vaccines; the halal status of vaccines; and distrust in the government/the political environment. Many participants stressed the issue of anti-vaccination and misinformation spreading on social media (including trans-nationally, which points the importance of media monitoring to serve as an early warning to prompt interventions to build public confidence in vaccines and immunisation). Participants from Indonesia, Lao PDR, Moldova, Nigeria, São Tomé and Príncipe, and Sudan discussed the impact of rumours and misconceptions. While most participants reported that mechanisms exist to investigate and respond to suspected adverse events following immunisation (AEFIs), they recognised that there is often failure to respond to misinformation rapidly and effectively.
• While some instances of complacency were mentioned, it was not a theme that emerged strongly from the in-depth interviews and focus group discussions.
• Accessibility issues, such as living in hard-to-reach areas and registering at a new clinic, were reported by participants as challenges to vaccination uptake.

Other findings:

• Participants' perception of the consequences of vaccine hesitation on immunisation coverage varied.
• Activities and strategies undertaken to assess vaccine hesitancy included: media monitoring, surveys and questionnaires, quantitative and qualitative studies, and periodic meetings with healthcare providers.
• Most LNCT country participants reported implementing interventions to address vaccine hesitancy, although a number of the interventions reported resembled standard immunisation communication tactics without specific attention to addressing the hesitancy issue. In most countries, rigorous evaluation of these interventions has not been done yet. Examples include:
  • Use of media
    • Sudan is addressing concerns using a radio show in the local language.
    • São Tomé and Príncipe uses social media, radio, and television to spread messages about vaccination.
    • Indonesia's Ministry of Health uses TV advertisements to encourage the public to accept vaccination and has developed messages for social media and WhatsApp.
    • Lao PDR uses a cartoon animation, translated into local languages, in health facilities and on local TV.
    • Vietnam and Moldova identified training journalists on how to report on AEFIs and how to communicate the benefits of vaccines as a priority.
    • Vietnam and Armenia engage and host training workshops with the media, including with journalists.
  • Social mobilisation
    • Sudan engages a variety of stakeholders, including community leaders and local doctors, in a targeted social mobilisation campaign in areas where they have experienced vaccine hesitancy.
    • Ghana uses a social mobilisation strategy that includes various planning committees that do media monitoring on social, traditional, and international media platforms.
    • Moldova has a national strategy, including a comprehensive communication plan, but financing the activities has been a challenge.
    • Georgia engages in various activities to address hesitancy, including FGDs, communication with doctors, communication with parents of children under 5 years old, and engaging with the education system.
    • Uzbekistan has developed and used a few promotional videos, but would like to further develop this intervention and translate videos from other countries.
  • Indonesia, Nigeria, and Sudan have held trainings and refresher trainings to build healthcare workers' confidence in vaccines.
  • Indonesia and Nigeria engage with religious and community leaders, providing them with information about vaccines.

Participants identified various areas they would like further support, such as assistance with developing information, education, and communication (IEC) materials to help increase the public's understanding of and confidence in vaccines and immunisation. Most countries identified the importance of peer learning to gain perspective on how other LNCT countries are addressing vaccine hesitancy.

One action point to emerge from the findings is related to vaccine hesitancy among healthcare providers, who have been found to have significant influence on the vaccine decision-making process. FGD participants from Georgia and Uzbekistan pointed to negative attitudes, lack of self-confidence, weak regulations, and lack of knowledge and training of healthcare providers influencing parents' decision to accept vaccination. As reported here, efforts to address vaccine hesitancy among healthcare providers should include information and training programmes to address their concerns and knowledge gaps, training to support communication between providers and patients (including managing difficult questions), and stronger accountability mechanisms.

In short: "Communication strategies were often cited by participants as an intervention for targeting hesitant populations; however, fear of side effects, concern about vaccine safety, and competing information that is accessible online will require more than filling information gaps. Efforts to build and maintain public trust are needed."

As the findings show, the manifestations of vaccine hesitancy at the local level are diverse, complex, and context and country specific. Therefore, there is a need to address them as such. In short, there is no one-size-fits-all solution to addressing vaccine hesitancy.

Click here in order to download the 37-page report in PDF format.