Key Considerations: Effective Vaccine Rollout and Uptake in Sierra Leone

"Vaccine acceptance is a complex social process rooted in specific socio-political contexts, as well as vaccine policy and messaging."

This brief, published by the Social Science in Humanitarian Action Platform (SSHAP), draws on evidence from academic and grey literature to propose key considerations for ongoing vaccination efforts in Sierra Leone. Developed mainly to inform the rollout of the new malaria vaccine, it draws on past experiences and evidence, including from routine childhood vaccination and polio immunisation programmes, to offer insights into how best to introduce and manage a new vaccine. The key considerations are meant to enable the United Nations Children's Fund (UNICEF) and health system stakeholders, including the Expanded Program on Immunization (EPI), the Directorate of Primary Healthcare, and the District Health Management Teams in Sierra Leone, to plan inclusive and equitable vaccine programming.

In discussing the specific contextual factors and considerations to support the rollout of the malaria vaccine in Sierra Leone, the brief looks in particular at the experience and evidence as it relates to the barriers to vaccine uptake, how socio-cultural factors and information shape vaccination trends, and factors that enable vaccine uptake. In relation to barriers in the context of Sierra Leone, the brief discusses health system challenges, access to vaccines, the impact of health emergencies and a militarised response to them, and historical legacies of fear. For example, the militaristic management of the Ebola outbreak has been shown to have important effects on vaccine confidence, diminishing vaccine access and eroding trust in authorities. In addition, the political and social context of Sierra Leone with its history of colonial extraction and war often causes people to fear vaccines as it is seen as a "ploy to kill the population". 

With regard to how socio-cultural factors and information shape vaccination trends, the brief considers how socio-cultural factors salient to different communities across Sierra Leone shape people's attitudes to vaccination, such as: religious beliefs; patriarchy and gender norms; the perceived risks of side effects; and rumours, concerns and misinformation. For example, one study of caregivers in urban informal settlements found that men usually determine decision-making on vaccination in the household. This finding reflects the fact that women often rely on their partners for reminders about scheduled vaccinations and financial support to cover direct and indirect expenses. The study also revealed that children whose mothers received strong support from their partners (by accompanying them to the clinic) were more likely to complete their vaccination schedule. In addition, fear of infertility as a side effect was considered a major obstacle, especially in Sierra Leone, where a woman's identity and social standing are deeply connected to childbearing. 

Learnings from research on the factors that enable vaccine uptake are taken from SSHAP's recent vaccine studies and engagement with vaccine stakeholders in Freetown, Kambia District, and other contexts in Sierra Leone. Factors that enable uptake include perceptions of safety and altruism, previous experiences with vaccines, inclusive communication and engagement, engagement of faith-based communities, efforts to build trust with local stakeholders, and public deliberation on the design of deployment strategies. For example, the research showed that vaccine uptake is often based on personal experience with vaccination and vaccine safety, as well as on the experiences of individuals' social networks. In a malaria perception study in Bo District, southern Sierra Leone, most participants stated they would be likely to vaccinate their children against malaria because of positive experiences with vaccination for diseases such as polio, measles, and hepatitis B, all of which had no severe side effects. These findings underscore the importance of sharing positive experiences of vaccination through community engagement and of ensuring that the first contact for vaccination is a respectful interaction. In addition, experience from other West African settings, such as the polio campaign in Nigeria, demonstrates the power of engaging faith-based communities among Muslim populations for improved uptake.

Based on the review, the report highlights the following key considerations: 
 

• Holistic improvements to service delivery strengthen vaccine confidence. Efforts to improve relations between healthcare workers and patients through training, codes of conduct, and fair wages for health staff in remote settings are examples of this approach.
• Investing resources in adapting to communities' access needs pays off. Consulting communities on their preferences and reflections on the most effective delivery strategies for their context (such as last-mile efforts, pop-up and door-to-door vaccinations) helps to sustainably address access issues.
• Emergency vaccination campaign planning must take into account the potential negative effects on routine vaccination. Strategies include effectively allocating time and resources to health staff or providing additional human resources to mitigate overburdening health facility staff.
• Emergency response modalities can negatively influence confidence in the health system. Militarised approaches (e.g., during the Ebola response) can erode trust in the health system during and after health emergencies and should be carefully considered.
• Community stakeholders must be at the centre of planning vaccine delivery, messaging, and outcome evaluation. This centring supports inclusive vaccine planning and delivery, strengthens community ownership, and helps address contextual challenges.
• Acknowledging and attending to the fears and concerns of the community builds trust. Fears and concerns surrounding vaccination are too often dismissed as "misconceptions". Recognising the legitimacy of communities' concerns and addressing them directly helps overcome mistrust of public health establishments.
• Developing localised approaches to community engagement builds vaccine acceptance. Social ties and identities influence how people engage with vaccines. Research to understand community dynamics helps inform tailored engagement approaches to address the realities and experiences of different social groups.
• Leveraging "enablers" of vaccination drives uptake. Rather than focusing solely on barriers to vaccination, research shows that narratives focused on protecting oneself and the community can be powerful drivers of vaccination.
• Employing a variety of communication channels is crucial to address mis- and dis-information. Traditional media and face-to-face methods of engagement help mediate how people engage with online information, supporting them to differentiate between the facts and false information.
• Gender-responsive and transformative vaccine programming helps address the challenges posed by gendered beliefs and practices. Adapting vaccine deployment strategies to address the impact of gender on behaviours and attitudes towards vaccines includes identifying opportunities to align immunisation goals with empowerment efforts.
• Addressing structural barriers to equitable healthcare delivery improves trust in vaccination programmes. Levels of trust must be understood in the context of structural drivers of inequities in accessing healthcare, such as health worker absenteeism and drug and medical supply stockouts.