Community Perceptions of Vaccine Advocacy for Children under Five in Rural Guatemala

"Despite a history of successful community-engaged vaccination campaigns across the world, community leaders' perceptions of child vaccines may not be uniformly positive."

Multiple barriers to timely vaccination exist in global health contexts, and vaccine hesitancy is a growing public health threat. National surveys published in 2020 indicate that, in Guatemala, only 59% of children aged 12-23 months are fully immunised. Historically, partnerships with community leaders (e.g., religious leaders, teachers) have been critical to building vaccination confidence, but a 2016 study of Guatemalan parents found that 32% of respondents thought community leaders did not support vaccinations for infants and children. So, in 2019, this research team surveyed 50 religious leaders, 50 community leaders, and 150 parents of children under five in rural Guatemala to assess participant vaccine hesitancy regarding childhood vaccines.

The study was conducted in the coastal lowlands of southwestern Guatemala near the border with Chiapas, Mexico. It centred around a survey that was based on the Theory of Planned Behavior, which emphasises the role of subjective norms, such as those set by community leaders, as they relate to individuals' preventive healthcare intentions and behaviours (e.g., vaccination). Surveys also included basic demographic questions, including those about religion and religiosity (assessed using the validated Duke University Religiosity (DUREL) tool).

Survey findings indicate that 14% of religious leaders and community leaders were vaccine hesitant, similar to community members (P = 0.71). For instance, one in three leaders expressed concerns that children get more vaccines than are good for them, and one in five thought it best for children to get fewer vaccines simultaneously. To address these concerns and others, the researchers suggest that physicians, nurses, and community health workers involved in local vaccination programmes should solicit leaders' questions and correct mistruths or misperceptions as they hear them.

While 85% of religious and community leaders felt comfortable with and responsible for talking about childhood vaccines in their communities, only 47% reported advocating in their communities in the prior year. This disconnect between perceived responsibility and reported actions suggests leaders may need concrete cues to action from public health leaders.

Whereas only 28% of parents trusted politicians "a lot" for vaccine advice, 72% trusted doctors (P < 0.01), 62% nurses (P < 0.01), 49% religious leaders (P < 0.01), and 48% teachers (P < 0.01). Thus, while parents of young children tended to primarily trust nurses and doctors for vaccination advice, in a multi-country study from 2016-2018 in which Guatemala was included, one in five parents reported strongly disagreeing with their healthcare provider's recommendation on vaccines. For such parents, advocacy from religious leaders or other community leaders may be especially influential. The present study "gives public health workers direction as they seek to choose community partners wisely to maximize a return of vaccination confidence on their partnership efforts." Specifically:

• In this survey, most community leaders were COCODEs, or members of Guatemalan Community Councils for Urban and Rural Development. COCODEs are elected by community assemblies and provide representation for communities on local matters. In lieu of seeking advocacy from high-level politicians, vaccination advocates should cue COCODEs to action (and equivalent leaders in comparable developing countries) and engage them in vaccine advocacy.
• Teachers may be especially important vaccination advocates. Their daily interaction with children and families, their involvement in school-based programming, and their longitudinal presence in communities may endear them to parents. Health officials could collaborate with teachers to host yearly "back-to-school" educational events, and/or teachers could coordinate with parents to review students' immunisation cards annually.
• Religious leaders dialogue with community members frequently, and they could be recruited as full partners in vaccination advocacy in rural Guatemala and similar contexts. To help build their capacity, public health officials could offer seminars on key topics: e.g., routine vaccination schedules, principles of individual or herd immunity, and common vaccine concerns and myths. Religious leaders may even desire to set up regular educational events or coordinate vaccine drives.

In conclusion: "This sentinel pilot study in rural Guatemala found religious leaders and community leaders were infrequently hesitant about childhood vaccines and were willing vaccination advocates. Half of community members highly trusted teachers and religious leaders for vaccination advice. Public health officials in rural Guatemala should enlist COCODEs, teachers, and religious leaders, address any concerns they have about childhood vaccines, and engage them as complementary partners in the important work of child vaccine advocacy."