Abstract
ObjectiveTo investigate vaccine hesitancy leading to underimmunization and a measles outbreak in Rwanda and to develop a conceptual, community-level model of behavioural factors.MethodsLocal immunization systems in two Rwandan communities (one recently experienced a measles outbreak) were explored using systems thinking, human-centred design and behavioural frameworks. Data were collected between 2018 and 2020 from: discussions with 11 vaccination service providers (i.e. hospital and health centre staff); interviews with 161 children’s caregivers at health centres; and nine validation interviews with health centre staff. Factors influencing vaccine hesitancy were categorized using the 3Cs framework: confidence, complacency and convenience. A conceptual model of vaccine hesitancy mechanisms with feedback loops was developed.FindingsA comparison of service providers’ and caregivers’ perspectives in both rural and peri-urban settings showed that similar factors strengthened vaccine uptake: (i) high trust in vaccines and service providers based on personal relationships with health centre staff; (ii) the connecting role of community health workers; and (iii) a strong sense of community. Factors identified as increasing vaccine hesitancy (e.g. service accessibility and inadequate follow-up) differed between service providers and caregivers and between settings. The conceptual model could be used to explain drivers of the recent measles outbreak and to guide interventions designed to increase vaccine uptake.ConclusionThe application of behavioural frameworks and systems thinking revealed vaccine hesitancy mechanisms in Rwandan communities that demonstrate the interrelationship between immunization services and caregivers’ vaccination behaviour. Confidence-building social structures and context-dependent challenges that affect vaccine uptake were also identified.
Highlights
Rwanda has a strong immunization system,[1] a well-organized vaccine supply system and a well-functioning community health worker (CHW) programme.[2]
For our study of underimmunization drivers in a lowincome country, we focused on measles in Rwanda, because: (i) measles is highly contagious and there were indications of underimmunization; (ii) measles increases morbidity and mortality because it erases the immune memory and increases susceptibility to other infectious diseases;[20,21] (iii) despite long-standing vaccination programmes, eradication has not been achieved globally according to the Global Measles and Rubella Strategic Plan 2012–2020;22 and (iv) the second measles vaccine dose was designated a performance tracer in the Immunization Agenda 2030.18 the measles programme is monitored by World Health Organization (WHO) and the Rwandan government, which can provide data for future quantitative models
There were no human capacity limitations that resulted in immunization services being unavailable and national immunization coverage rates were above 90%
Summary
Rwanda has a strong immunization system,[1] a well-organized vaccine supply system and a well-functioning community health worker (CHW) programme.[2]. A major driver of underimmunization is vaccine hesitancy,[5] which is defined by the World Health Organization (WHO) as “delay in acceptance or refusal of vaccination despite availability of vaccination services.”[6] According to WHO, “vaccine hesitancy is complex and context specific, varying across time, place, and vaccines” and is one of the top 10 global health threats.[6,7]. WHO’s Immunization Agenda 2030 highlights the importance of people-centredness for understanding the context-specific root causes of vaccine hesitancy and for co-designing solutions.[18,19] the literature has major gaps on: (i) the analysis of human-centred design approaches; (ii) the relationship between beneficiaries and service delivery; and (iii) incorporating the interaction between hesitancy factors into policy and intervention design.[6]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
