A Behavioural-Theory-Based Qualitative Study of the Beliefs and Perceptions of Marginalised Populations towards Community Volunteering to Increase Measles Immunisation Coverage in Sabah, Malaysia

"Community-based engagement activities should be included in the current strategy to overcome the challenges faced in the eradication of measles."

As is the case in many countries, the challenges of increasing measles immunisation coverage in Malaysia include low vaccination coverage and vaccine hesitancy in certain demographics. In the state of Sabah in Malaysia, it is difficult for marginalised populations to receive a complete course of measles immunisation, which involves vaccinations at the ages of six, nine, and twelve months. The public health domain has relied on community volunteering strategies to increase immunisation rates, but most volunteers are from majority populations - in part because marginalised communities face many daily obstacles that have to be addressed if they are to participate in community volunteering. This study used behavioural theory (BT) to examine the beliefs and perceptions of a marginalised population towards community volunteering as a method of increasing measles-containing vaccine (MCV) coverage.

The qualitative study was conducted over from April to December 2022. Marginalised populations living in Kota Kinabalu, Sabah - more specifically, Malaysian citizens living in urban slums and squatter areas, as well as legal and illegal migrants - were extensively interviewed in person. The 40 respondents were either the parents or primary caregivers of at least one child under the age of five. A dual-language, semi-structured questionnaire was designed in both English and Malay on the six components of the Health Belief Model (HBM) - namely, perceived susceptibility, perceived severity, perceived effectiveness, perceived barriers, cues to action, and self-efficacy. These same HBM components were then used to examine the collected data.

The paper features direct quotes from respondents, as well as a discussion of the findings. In brief:

• Perceived susceptibility: A few respondents believed they were not likely to contract measles as no one in their family had had it. Nevertheless, these same individuals acknowledged that children should be vaccinated, as the MCV provides immunity and protection to children. Unfortunately, a few respondents had negative perceptions of the MCV due to the COVID-19 pandemic. Therefore, community volunteers are needed to assist and educate them on the matter.
• Perceived severity: Most of the respondents viewed contracting measles as a trivial health issue, as children would only develop skin rashes and a fever that could be treated with medicine.
• Perceived benefit: Most of the respondents believe that measles vaccination is needed for the health of their children. They also felt that community volunteers could help explain, share knowledge, and remind parents of their children's vaccination appointments. They also felt that volunteers could help encourage, placate, and convince individuals who distrusted childhood vaccinations after the COVID-19 pandemic that their children needed the MCV. Volunteers could also act as spokespersons of village communities and communicate with healthcare professionals when individuals are unable to visit a clinic in person. However, several respondents felt that it is better and more beneficial to deliver the free MCVs to villages.
• Perceived barriers: Obstacles to receiving MCV included: a nomadic lifestyle; issues with finances, citizenship status, language, and weather; failure to remember immunisation schedules; a fear of healthcare personnel; too many children; and a lack of female autonomy in vaccine decision-making.
• Cues to action: Most of the respondents were receptive towards community-based programmes, and many welcomed a recall or reminder system, especially when the volunteers were family members or neighbours who spoke the same language and knew their village well. A few, however, found it awkward to have volunteers assisting them.
• Self-efficacy: Most respondents made an effort to have their children vaccinated. Meanwhile, a few turned to the nurses or their family members if they had immunisation-related questions.

In reflecting on the findings, one theme that emerges is the way in which the COVID-19 pandemic altered the attitudes of mothers towards childhood vaccinations and resulted in decisions to leave their children unvaccinated. Marginalised and majority populations in Malaysia have various concerns regarding vaccines that can lead to hesitancy. Most Malaysian parents express concerns about the safety, side effects, and efficacy of vaccines, as well as myths, such as that children are receiving too many immunisation shots and that natural infection is a better way of building immunity. Furthermore, religion, superstition, and a preference for holistic medicine add to the general mistrust of conventional medicine and healthcare providers.

Nevertheless, most of the respondents of this study believed that community volunteering would increase the uptake of the MCV. Per the HBM, such a programme should aim to increase the perceived susceptibility and severity of measles. Improving self-efficacy also correlates with the adoption of recommended behaviours. The results also indicate the importance of choosing community volunteers with whom marginalised populations are acquainted and familiar. Obtaining the trust and confidence of the community in the volunteer programme could encourage the community to be more self-sufficient in the long run.

As outlined here, communicating information and attracting attention should be a priority when a community volunteering programme is initiated. The media is an effective method of communicating the importance of vaccination and garnering public support. Conversely, poor communication can aggravate vaccine scepticism and lower vaccination rates. The message and language used to outline vaccine goals to a marginalised population must be comprehensible if they are to trust immunisations and increase vaccination rates. Furthermore, highlighting the dangers of vaccination decreases the intentions of individuals to get vaccinated. Therefore, "the dangers should be vaguely expressed while an emphasis should be placed on lowering the risk of infection. Lastly, humour has been found to attract and lower reactance which, in turn, decreases vaccine hesitancy in a community."

In conclusion, this study provides an understanding of "the prospective messages and message delivery methods that can be used by community volunteer programmes in middle-income countries, especially to garner the participation of marginalised populations. One method is the implementation of a straightforward recall and reminder system that is run by the community in question. This way, the community would encourage, inform, and persuade parents and caregivers to have their children vaccinated. Future studies could examine methods of implementing community volunteer programmes, as well as assess the success and impact of such programmes in increasing the coverage of measles immunisation."