Exploring Perceptions and Attitudes towards Vaccines in a Remote Western DRC Health Zone

"It is important to recognise vaccine confidence as a dynamic concept influenced by various factors....This highlights the importance of continuous assessments of confidence levels in different regions of the world to be able to address potential drops in a timely and context-tailored manner."

The Democratic Republic of the Congo (DRC) struggles with low full childhood vaccination coverage (around 50%) and a high children-under-five mortality rate (79 deaths per 1,000 live births). This situation is potentially exacerbated by vaccine hesitancy. To gain deeper insights into levels of vaccine confidence possibly influencing vaccination coverage, this study explored perceptions and attitudes towards childhood and adult vaccines in the remote town of Boende (Tshuapa province, western DRC), which experienced an Ebola outbreak in 2014 and hosted the EBL2007 Ebola vaccine trial (2019-2022). The study also sought to identify best practices during sensitisation and vaccination campaign activities, recognising that although vaccine confidence plays a crucial role, it is not the sole factor contributing to low vaccine coverage in the area.

Using purposeful sampling, the researchers conducted 29 individual interviews and 14 focus group discussions with diverse community members between July 2022 and March 2023.

The findings suggest the prevalence of a relatively low level of trust in COVID-19 vaccines compared to other vaccines. In fact, reports have shown that the DRC has one of the lowest COVID-19 vaccine confidence and uptake levels in the African continent and that trust levels even decreased between 2020 and 2022. The confidence situation in the country is complex, and several factors could contribute to this, which are often also applicable in other countries, such as distrust in the healthcare system, corruption, and challenges related to vaccine production and accessibility. However,  country-specific factors could have also exacerbated this phenomenon; for example, the volatile political scene at the time of the vaccine rollout, as well as an Ebola outbreak between 2018 and 2020 that killed more than 2,000 people in over a year and a half.

On that note, the fear of Ebola disease seemed to lead to general acceptance of the EBL2007 trial vaccine, although some concerns were voiced about pre-testing and the decision to conduct the trial in the DRC. ("Why do the whites come to do their vaccine study only in the DRC?")

While the study participants voiced opinions, worries, and recommendations in response to questions about the Ebola trial vaccine and adult vaccines in general, a predominant focus on childhood vaccines emerged when they were talking or giving examples about vaccines. This fact likely reflects the population's greater familiarity with childhood vaccines due to their longer inclusion in state-provided health services, unlike vaccines that are rolled out in special outbreak situations.

While trust in childhood vaccines and reported uptake appeared to be high, concerns existed regarding potential adverse effects and the possibility that vaccines were exclusively administered to black African populations in low-income countries. Another set of reasons for distrust stemmed from the infrastructure and human resources components of a vaccination activity, especially in rural settings. Primarily, some participants were worried about the preservation and transportation conditions of vaccines allocated to remote villages.

Although many interviewees voiced concerns about childhood vaccines, the majority of participants had their own children (or the children of their family members) vaccinated. Furthermore, people stressed the fact that although side effects scare them, they do not categorically refuse vaccines.

When asked what could facilitate (childhood) vaccination, many people mentioned good practices witnessed in Boende, such as:
 

• Passing information about vaccination campaigns using megaphones in the streets: This approach was found to be particularly effective at night or around 5 a.m., when the town is still quiet and most people have not left for their jobs yet. Another appreciated vaccination information source was the radio, at the same times of the day. House-to-house vaccination was preferred to calling people to come to vaccination centres.
• Publicising vaccination activities in the presence of healthcare providers who would receive the vaccine in front of the public: Several interviewees praised the fact that the head of the Boende General Reference Hospital took the COVID-19 vaccine in public.
• Including pictures of white adults and children being vaccinated in vaccination campaigns and other forms of vaccine communication to reassure people that immunisation programmes run worldwide.

Based on the results, and echoing some of the participants' own suggestions, the researchers outline specific and actionable recommendations that could help increase trust in vaccines in areas like the study region (Tshuapa province):
 

1. Disseminate knowledge about vaccine-associated adverse events: Attention should be paid to people's concerns so as to better tailor sensitisation messages to the needs of the population.
2. When recruiting for late-stage clinical trials, inform potential participants about where the initial stages of the trial were conducted: Addressing concerns and misinformation about the concentration of vaccine trial sites in Africa and the lack of pre-trial testing is crucial. It could be feasible to show that most investigational products with phase 2 and 3 trials in African countries have often undergone phase 1 trials in non-African countries.
3. Ensure representation of individuals from various skin colours and countries in vaccine-related communication to help dispel suspicions and reassure communities: In countries that endured colonisation, like in sub-Saharan Africa, vaccine hesitancy may be compounded by historical trauma from colonial atrocities and/or unethical clinical trials lacking valid informed consent. While many international guidelines call for ethnically representative (or inclusive) and culturally sensitive forms of health communication, for many of the study participants, showing only black adults and children in vaccine-related health communication inadvertently led to suspicions.
4. Have healthcare providers or authority members vaccinated and vaccinate their children in a public space for other community members to see: Vaccine hesitancy among healthcare providers is a well-documented issue that threatens to lower general vaccine confidence levels in communities worldwide. Public vaccination of these providers could be used for both adult and childhood vaccines.

Thus, this study highlights the multifaceted nature of vaccine confidence, influenced by the perceived risk of the targeted diseases, past experiences with medical interventions and staff, and sociopolitical contexts. Increasing vaccine uptake requires a comprehensive, multidisciplinary approach that addresses not only vaccine confidence but also aspects like access to vaccines and robust disease surveillance activities.