Relationship between Household Member Vaccine Acceptance and Individual Vaccine Acceptance among Women in Rural Liberia

"Social norms around vaccine acceptance within households are strongly associated with individual acceptance. Interventions that target hesitant households and individuals could have a significant impact on vaccine acceptance rates."

Despite the availability of COVID-19 vaccines, vaccination uptake remains low in Liberia. Many studies have found that concerns about vaccine safety, particularly regarding its fast production, have plagued the COVID-19 vaccine-hesitant population. Social norms, and in particular an individual's family preferences, can have a strong normative influence on health behaviour. Motivated by a belief that better understanding how knowledge is shared within households might inform targeted vaccination programme design and interventions focused on addressing vaccine hesitancy, this group of researchers undertook a study to: (i) determine how vaccine acceptance beliefs cluster within households and (ii) estimate the association between household vaccine acceptance and individual vaccine acceptance among women in rural Liberia.

Data were analysed from a household survey of 2,620 women aged 15-49 in 2,201 households in rural Grand Bassa County, Liberia, from March to April 2021. The survey included a COVID-19 module on protective health behaviours and intention to accept a COVID-19 vaccine when available. Each household was defined as being concordantly vaccine-hesitant, concordantly vaccine-accepting, or discordant (households whose respondents had discordant COVID-19 vaccination beliefs). A multivariable logistic regression model was fitted to identify correlates of concordant acceptance, adjusting for potential confounders.

Among individual respondents, 47% were vaccine accepting (n=1,229) and 53% were vaccine hesitant (n=1,376). The 2 groups were significantly different for COVID-19 knowledge and behavioural factors, including having heard of COVID-19 (P<0.001), being able to correctly identify routes of COVID-19 transmission (P=0.001), being able to correctly identify safe COVID-19 practices (P<0.001), owning a face mask (P<0.001), intent to seek care if they had COVID-19 symptoms (P<0.001), and intent to take a COVID-19 test if they were sick (P<0.001).

The survey found that only approximately 1 in 3 households in rural Liberia were fully COVID-19 vaccine accepting. About 42% of households had discordant views on the vaccine, while 33% had concordantly accepting views, and 25% had concordantly hesitant views. Having a household member who accepted the COVID-19 vaccine was associated with an 18.1 percentage point greater likelihood of an individual accepting the vaccine (95% confidence interval (CI)=7.3-28.9%, P=0.001). Another predictor of vaccine acceptance was living 10 to less than 20 kilometers from the nearest health facility, compared to living less than 10 kilometers from the nearest health facility (95% CI=0.2-13.8%, P=0.043).

After the Ebola epidemic, Liberia designed and scaled the National Community Health Assistant (NCHA) programme to increase access to primary healthcare for remote communities and improve pandemic response. As part of the NCHA programme, all deployed community health workers (CHWs) were trained on COVID-19 prevention practices and surveillance. The study found that participants living in NCHAP-implementing districts were more likely to be accepting of a COVID-19 vaccine than participants in districts that have not yet implemented NCHAP. One strategy employed by the NCHAP implementation team in Grand Bassa county was to ensure almost 100% COVID-19 vaccine coverage among community health assistants (CHAs). Fear of COVID-19 vaccination may have been alleviated when community members saw CHAs - trusted members of their community - accepting the vaccine. Therefore, the NCHA programme may promote willingness to receive COVID-19 vaccination among community members.

In short, this study found that the strongest predictor of whether someone was accepting of the COVID-19 vaccine was whether someone else in their household was also vaccine accepting. These data support the notion that social contagion - that people's decisions are influenced by the behaviour of others around them - and emphasise the importance of social norms for vaccine acceptance in rural Liberia. It also suggests that a target for vaccine hesitancy interventions may be discordant households where changing the pro-vaccine attitude of one household member could influence other members of their home.

In conclusion: "Policy makers, advocates, and programs should promote the implementation of door-to-door vaccination interventions that target vaccine hesitant households as well as individuals, as this may have a significant impact on vaccine acceptance rates in remote settings....Targeted vaccination programs should leverage community members with higher education, CHWs, and trusted community members to act as role models for health behavior and lead health education and promotion efforts. The positive association between education and vaccine acceptance emphasizes the importance of education programs that target women in improving the health of communities. Vaccination and education programs that leverage the influence of family members and trusted members of the community, such as CHWs, should be implemented to target misinformation and address concerns around the COVID-19 vaccine, and improve vaccination rates, knowledge, and safe practices among community members."