Addressing Vaccine Hesitancy in Religious Communities in Manicaland, Zimbabwe

Research
UNICEF, in collaboration with the World Health Organization (WHO) and the Zimbabwe Ministry of Health and Childcare (MoHCC), conducted rapid behavioural assessments in May 2022 to identify barriers and motivators to the uptake of the polio vaccine amongst caregivers through a short message system (SMS)-based survey called U-Report. The research involved 3,451 respondents (1,728 males and 1,710 females). Findings revealed that only 51% of the respondents had heard about polio, and, of these, 30% had heard about it from village health workers (VHWs). Comparative U-Report results indicated an increase in caregivers willing to get their children vaccinated (89%) from the October 2021 poll to May 2022. However, there remained a significant proportion of non-compliant caregivers who expressed concerns about side effects and vaccine safety.

Rapid qualitative assessments were also conducted in select communities to identify the key drivers of vaccine hesitancy, refusal, and acceptance - which include socio-cultural and religious, political, and institutional factors - and how these drivers influence acceptance and non-acceptance of vaccination services and, more broadly, maternal, newborn, and child health (MNCH) services. Sixty participants - religious leaders, caregivers, VHW and district staff - took part in focus group discussions (FGDs) and in-depth interviews (IDIs). Caregivers cited religious doctrine, beliefs, and practices as some of the reasons for their vaccine refusal and hesitancy.

Specifically, the negative perceptions of modern medicines and health services are embedded in Apostolic religious views that see their use as a sign of a lack of faith in God, ignoring the spiritual dimensions of health and child diseases, and low confidence in the Apostolic healing system (faith healing rituals such as prayer, holy water, faith healers including prophets, and Apostolic birth attendants). Modern medicines and vaccines are often perceived as dangerous and the cause of diseases or deaths. The findings also revealed that caregivers had limited knowledge and understanding of vaccination, and seldom identified the vaccine with specific diseases. They understood vaccination as merely "injections" and lacked the confidence to ask health workers about specific vaccines and diseases - therefore not fully understanding the risks of missing/skipping vaccines in stipulated vaccination schedules.

The assessment also highlighted the importance of health worker and caregiver relationships and their role in influencing the uptake of vaccination services for children. Caregivers complained about the negative attitude of some health workers. They also indicated that some health workers hardly spend time explaining the vaccines, symptoms of vaccine-preventable diseases, the benefits of vaccination, and the importance of adhering to the vaccination schedules.

The SBC intervention
Based on the findings, UNICEF Zimbabwe developed a plan to shift social norms around vaccines. The plan adopted a blended theoretical model, including an ecological and an individual perspective. The audience segmentation was conducted using the socioecological (SEM) model (1977), which focuses on individuals, families, communities, organisations, and policymakers. The demand strategy primarily prioritised three audience groups: accepters, rejecters, and key influencers (religious and community leaders). Communication at the individual level was conducted by trained VHWs, while community engagement interventions were designed for high-risk locations. Religious interlocutors were engaged to support social mobilisation and to influence role modelling efforts - for example, the vaccination of their children in public places.

The SBC response plan adopted a multi-pronged approach that included the following: 
 

• Coordination: Under the leadership of the MoHCC and with support from UNICEF, WHO, and Rotary/Zimbabwe, subnational coordination mechanisms were reactivated to support microplanning, community mapping, and the collection of feedback from communities.
• Situation analysis, regular collection of insights, and rumour tracking: Monthly behavioural analyses were conducted through U-Report polls and Open Data Kit (ODK) knowledge, attitudes, and practices (KAP) assessments. These analyses were conducted before and after campaigns to help inform SBC strategies and messaging.
• Interpersonal communication and community engagement in high-risk areas: A network of more than 3,000 village workers (some recruited from within the Apostolic sects) and religious leader champions were instrumental in conducting house-to-house engagements to facilitate family-led conversations that addressed fears and perceptions and reinforced trust in the polio vaccine.
• Community advocacy with religious leaders: To engage these communities, UNICEF partnered with a local community-based organisation Apostolic Women Empowerment Trust (AWET) to train vaccine champions, who were instrumental in building trust in health services with conservative groups and in endorsing the polio campaigns.
• Leveraging of radio platforms to promote key messages: UNICEF partnered with the Zimbabwe Broadcast Corporation and a regional community radio station, Diamond FM, to broadcast polio campaign messages, caregiver testimonials, interviews with health experts, and information on when and where to get the polio vaccine. The radio platforms and key messages reached more than 1 million people.
• Standardised communication materials for communities, schools, and health facilities: SBC materials with tailored key messages were developed and displayed in strategic places. These materials were designed to inform and mobilise communities during campaigns.
• Listening, collecting, and responding to community feedback: VHW and behaviour change facilitators carried out community meetings and dialogues to, among other things, identify rumours and collect feedback. This information was then used to inform further communication via radio, community leaders, and the mobilisers.

Immunisation and Vaccines, Polio

Context (as per "Addressing and Shifting Social Norms and Harmful Practices That Hinder Demand and Uptake of Polio Vaccine Among Vaccine Hesitant Communities in Manicaland Province, Zimbabwe" [PDF]):

The Apostolic religion is one of the largest faith groups in Zimbabwe, with followers living predominantly in Manicaland Province to the east of the country bordering Mozambique. According to the 2010/2011 Zimbabwe Demographic and Health Survey (ZDHS), the Apostolic religion is followed by 33% of Zimbabwe's women and men aged 15-49. These ultra-conservative groups have a negative influence on health-seeking behaviours, including the use of modern reproductive, maternal, neonatal, child, and adolescent health, nutrition, and HIV (RMNCAH-Nutrition and HIV) services. Apostolic religious doctrine, beliefs, and practices reject modern health services and medicines and can constrain followers' choices and decisions in seeking medical care. The April 2022 measles outbreak in Zimbabwe demonstrated that households affiliated to the Apostolic faith had high numbers of unvaccinated children and high rates of measles cases and infant mortality. DPT3 (a combination vaccine that protects against diphtheria, tetanus, and pertussis) coverage in the target districts prior to the campaign ranged between 60-70%.

Results:
 

• 95% coverage achieved - higher than the national DPT3 coverage of 83%.
• 87% of households reported having been visited by a social mobiliser in Round 2 compared to 77% in Round 1.
• 93% of people were informed about the campaign dates in Round 2, compared to 91% in Round 1.
• 99% were ready to vaccinate in Round 2 compared to 91% in Round 1.
• Community cadres and leaders trained: 1,350 behavioural change facilitators (BCFs), 715 councillors, 1,570 traditional leaders, 850 faith leaders, and 3,108 VHWs.

Lessons learned:
 

• Social science research was crucial in shaping the social mobilisation strategy. A pre-campaign ODK/KAP assessment collected data on the reasons for missed children and the main sources of campaign information for communities, which can also be used for better planning of future campaigns, including COVID-19 vaccine campaigns.
• The use of VHWs recruited from the Apostolic sect as social mobilisers meant that they understood the fears of religious objector communities. However, the campaign could have benefitted more if other volunteers like town criers had been recruited from the same population to increase acceptability.
• To ensure immunisation objectives can be achieved, polio campaigns need to be integrated into other public health efforts to maximise resources. The campaigns would have yielded maximum benefits for women and children if vitamin A supplements and other high-impact interventions such as nutrition screening, birth registration, and deworming were conducted during the campaigns.
• Investment in reciprocal religious and scientific literacy helped build acceptance and positive role models.
• VHWs played an important role in sharing accurate and timely information about polio. In some areas, however, VHWs lacked motivation. Strategies to motivate and retain VHWs are essential. These might include providing regular training opportunities, investing in visibility, and offering some form of acknowledgement. Adequate compensation and transportation are also important for VHWs to effectively perform their tasks.
• Engaging communities and conducting community mobilisation were key to building confidence in the campaign and to addressing the spread of misinformation. However, community engagement activities should have begun several weeks in advance of the campaign to provide information on the reasons for the campaign.