Factors Influencing Vaccine Acceptance and Hesitancy in Three Informal Settlements in Lusaka, Zambia

The World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) defines vaccine hesitancy as the delay or refusal of vaccination despite its availability. People may delay or refuse vaccination due to lack of confidence in recommended vaccines and providers, complacency shaped by context (e.g., distance to health services, culture, or history), and individual and vaccine-specific factors. Evidence on determinants of vaccine hesitancy in Zambia is scarce, so these researchers investigated overarching perceptions on vaccine acceptability, hesitancy, and accessibility at three informal settlements ("compounds") in Lusaka, Zambia.

This qualitative study was nested within a larger study on the uptake of 2-dose oral cholera vaccine (OCV) in these compounds. Approximately 1.2 million people living in Lusaka compounds are at risk of vaccine-preventable diseases due to a crowded, unsanitary environment and differential vaccine uptake. During February 2016, a cholera outbreak affected several compounds, with 1,054 cases reported. In response, the Zambian Ministry of Health began a reactive 1-dose OCV campaign in May 2016, followed by a preemptive campaign in December 2016. This provided the researchers with an opportunity to hear communities' voices on vaccines and contribute to the explanation of differences in vaccine coverage observed in Zambia.

The researchers conducted a rapid qualitative assessment that included 48 focus group discussions (FGDs) with residents and community-based health actors - lay healthcare workers (HCWs), vaccinators, and neighbourhood health committees (NHCs). A total of 281 laypersons and 197 community-based health actors participated in the FGDs, distributed evenly between compounds. Notably, 45% reported receiving zero OCV doses, followed by one and two doses, at 28% each. The majority of the participants had children (64%), and most (93%) of those with children said they would agree to vaccinate them. Responses from health actors were very much in tune with those in the community, likely because they are from the community and not professionalised.

All discussants expressed high acceptance of vaccines, associating vaccinations with child health and modernity. However, participants said that some individuals in their community may refuse or delay getting vaccinated (see Tables 2 and 4 in the paper for themes and sub-themes related to acceptability and perceived safety, with supporting quotes). The researchers describe competing traditional and religious beliefs. For example, participants cited cases of young men using beer, spirits and local alcohol, Tujilijili, Junta, and Kachasu, while others used other informal and traditional alternatives such as traditional brews, herbs, and tattoos. Some people avoided vaccination on religious grounds, explaining that any intervention went against God's way - for example, "God did not take any medicine" - and was associated with Satan. In particular, HCWs described some churches that promoted faith healing over modern medicine. Use of prayer and traditional remedies could be fuelled by distrust of modern medicine, which is still perceived as "white" or "western"; this distrust finds its roots in colonial history of exploitation and appropriation. Previous experience with biomedical research and vaccine-related adverse events associated such as fever made individuals hesitant. Also, some FGD participants reported refusing injections to avoid pain and perceived risk of infection. Social interactions perpetuated these views and information, leading to vaccine hesitancy.

Limited understanding of how vaccines work also created unrealistic expectations (see Table 5 in the paper for quotations related to misconceptions and perceived effectiveness). Language can be an important communication roadblock here; in Lusaka, where Nyanja is more colloquial than formal, "Mankwala" is the synonym for vaccine and medicine. In Bemba language, vaccine is called "umuti uwakuichingilila" (medicine for protection), which could easily have respondents believing in medicines as prevention and vaccines as treatment. The researchers caution that such unrealistic expectations can lead to vaccine hesitancy if immunised individuals become ill. In such a scenario, distrust can go beyond vaccination and, combined with existing rumours and concerns, compromise trust relationships with providers and the health system.

Community members' suggestions and preferences for addressing vaccine hesitancy focused on improving vaccine literacy and access to vaccines. As shown in Table 6 in the paper, laypersons wanted more "education about the vaccines" because they are "just told that you should come for the vaccines at the clinic" without being informed on what to expect. The researchers suggest that, to maximise uptake, educational and vaccination campaigns should align with communities' preferences for door-to-door delivery on weekends by volunteers from the same communities. Educational and engagement efforts should seek to reach key influencers such as elders and religious leaders and also be embedded in services for key groups such as pregnant women. Based on this research, education should provide information on vaccines' aim and possible adverse effects in order to limit the spread of rumours and distrust. Furthermore, to address misconceptions about vaccine effectiveness and prevent future frustration leading to vaccine hesitancy, vaccine-related education should be preemptive, differentiate between vaccines and other medical products using clear language, and be clear with regard to the effectiveness of different vaccines. Increased transparency and information to communities through trained community advisory boards selected from the same community also seems a promising approach to improve understanding.

In conclusion, the researchers recommend further research to understand how lack of sufficient information drives vaccine hesitancy, to identify whether rumours and competing beliefs affect particular groups and what are the most effective ways of providing education and improving access.