Harvard T H Chan School of Public Health (SteelFisher, Blendon, Lodge II, Caporello); John F Kennedy School of Government (Blendon); UNICEF (Guirguis, Petit, Coleman, Corkum); Ministry of Public Health, Kabul, Afghanistan (Parwiz); InterMedia (Gardner); SSRS (Ben-Porath)
"To enhance OPV commitment, it might be useful to consider a multifactorial approach that highlights building trust in vaccinators, providing facts about transmission, sharing positive messages to overcome key rumours, and strengthening community support for vaccination."
In an effort to guide communication, community engagement, and operational efforts to support polio eradication, this quantitative study describes and assesses the relationship between caregivers' knowledge, attitudes, and vaccination experiences, and their commitment to vaccinate their children. In Afghanistan, one of the remaining polio-endemic countries. There, delivery of oral polio vaccine (OPV) through door-to-door campaigns is the foundation of the polio programme. But there are many plausible threats to caregiver commitment to accept OPV every time it is offered, which can be many times each year. To help understand this, the researchers conducted a poll of caregivers in areas of Afghanistan at high risk for polio transmission, examining the reported commitment to accepting OPV every time it is offered until a child is 5 years old and which plausible threats are associated with lack of commitment.
Between Dec 19 2014 and Jan 5 2015, the researchers interviewed 1,980 caregivers, 21% of whom were "uncommitted" to accepting OPV. The questionnaire consisted of 55 questions informed by experiences of those working in Afghanistan's polio programme and by studies of barriers to acceptance of OPV and other vaccines. The questionnaire covered intent to accept OPV (polio drops) until a child is 5 years old and each of 5 hypothesised threats: limited concern about polio and limited knowledge of transmission and harms, negative perceptions of vaccinators and institutions organising OPV efforts, perceptions that prominent community members lack support for OPV efforts, perceptions that peers lack support for OPV efforts, and awareness of and belief in negative rumours about OPV.
- 40% of those whose child did not receive OPV in the last campaign said they were uncommitted, compared with 19% of those whose child did receive OPV in the last campaign.
- Caregivers who are not "very concerned" about their child contracting polio were more likely to be uncommitted than were caregivers who are "very concerned" (33% vs 15%). The same was true for caregivers who did not believe the disease would be "very serious" compared with those who thought it would be (41% vs 18%).
- Caregivers who did not know that polio can be spread by contaminated food or water were more likely to be uncommitted than were their more knowledgeable counterparts (contaminated food, 31% vs 14%; contaminated water, 41% vs 14%).
- Caregivers who did not trust the vaccinators "a great deal" during the last visit were more likely to be uncommitted than caregivers who did (54% vs 9%). The same is true for caregivers who did not think vaccinators cared "a great deal" about their child's well-being compared with those who did (46% vs 10%).
- Caregivers were asked to identify groups, organisations, or government agencies responsible for OPV efforts and report their trust in these institutions. Caregivers who did not trust "a great deal" at least one of the institutions mentioned were more likely to be uncommitted than were caregivers who did trust at least one "a great deal" (33% vs 20%).
- Caregivers who reported that their religious leaders believe giving OPV to children in the neighbourhood is not a "very good idea" were more likely to be uncommitted than were caregivers who reported the opposite (25% vs 17%). The difference when considering community leaders was 24% versus 18% (p=0·0529). Caregivers who reported that their neighbours believe giving OPV to children in their neighbourhood was not a "very good idea" were more likely to be uncommitted than were caregivers who thought the opposite of their neighbours (24% vs 17%).
- Caregivers who were aware of the rumour that OPV is "very likely to give a child polio" were more likely to be uncommitted than were caregivers who were unaware of this rumour (39% vs 16%). The same is true for caregivers aware of the rumour that OPV is "not halal" compared with those unaware (37% vs 15%). Belief that each of these two rumours could be at all true (i.e., not completely false) was also associated with lack of commitment ("very likely to give a child polio", 53% vs 17%; "not halal", 50% vs 21%), as was any belief in the rumour that OPV can "give a child HIV/AIDS" (31% vs 16%).
These findings suggest that:
- Views of vaccinators have an important role in caregiver commitment to accepting OPV in the future; by contrast, perceived vaccinator knowledge did not appear to have a role. These data suggest that programmes should address perceptions of vaccinators beyond technical merits. Selecting vaccinators who will be trusted by the community and providing communication training to improve interactions between vaccinators and caregivers could be crucial.
- Previous studies have suggested that factual knowledge is not related to commitment, but this study found that some factual knowledge - knowing how polio is transmitted - was related to commitment. However, knowing polio's most prominent symptom, paralysis, was not related to commitment. Perhaps caregivers are not motivated to accept OPV by knowing about paralysis since they already assumed polio was harmful. Explaining modes of transmission, and perhaps more broadly identifying motivating information, could therefore be an useful approach in communications.
- Awareness of and belief in some - but not all - negative rumours are threats to OPV commitment. Rumours about religious acceptability and that OPV very likely causes polio were associated with commitment. Thus, as part of strategies to reduce the impact of rumour circulation, it might be important to have messages that situate OPV within cultural norms, particularly religious acceptance, as well as those that highlight its overall safety.
- Believing that religious leaders and neighbours do not strongly support OPV was associated with lack of commitment, although the associations were not as strong as for some other factors. These data suggest that building community support is a secondary means of enhancing commitment.
In conclusion, this study suggests the utility of a multifactorial approach that highlights building trusting relationships with vaccinators (e.g., through selection of workers from the community), providing facts about transmission modes, and including positive messages to reduce the impact of key rumours. Lessons from the study might also help to guide programmes in other countries where repeated rounds of OPV are still used to support global eradication. Additional research, including mixed methods approaches, could be needed to adapt these lessons in the local context of other countries.
The Lancet Infectious Diseases 2017; 17: 1172-79. http://dx.doi.org/10.1016/ S1473-3099(17)30397-3. Image credit: Voice of America