insights into vaccine hesitancy from systems thinking, rwanda

Bull World Health Organ 2021;99:783–794D | doi: http://dx.doi.org/10.2471/BLT.20.285258

Research

783

IntroductionRwanda has a strong immunization system,1 a well-organized vaccine supply system and a well-functioning community health worker (CHW) programme.2 As a result, national im-munization coverage rates are high and new vaccines are introduced swiftly.3,4 Nevertheless, some communities still face local disease outbreaks due to underimmunization. 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

Factors influencing vaccine hesitancy can be categorized using the 3Cs framework: (i) confidence; (ii) complacency; and (iii) convenience.8 As psychological, sociological and environ-mental drivers are paramount in instigating the behavioural changes required to address vaccine hesitancy,9,10 understand-ing the contextual relationships between vaccine hesitancy and socioeconomic determinants of health is crucial.11–16 Additionally, better understanding of vaccine hesitancy is needed to achieve the sustainable development goals, including universal access to quality vaccines.17 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 However, 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

For our study of underimmunization drivers in a low-income 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 Moreover, the measles programme is monitored by WHO and the Rwandan govern-ment, which can provide data for future quantitative models. In Rwanda, the measles vaccination programme has been quite successful: it achieved a national coverage rate above 85% for the second measles and rubella vaccine dose in 2015 and reached the target national coverage rate of 95% for the first dose in 2017.18,23 The first measles and rubella vaccine dose is administered 9 months after birth and, since 2015, the second dose is administered 15 months after birth. Despite these achievements, Rwanda still faces sporadic measles outbreaks (e.g. in Western Province in 2019).24

To inform policy design and to improve immunization levels, we aimed to study the mechanisms underlying vac-cine hesitancy in Rwanda that contributed to local underim-munization for measles and a subsequent measles outbreak. We conducted an analysis of immunization service delivery

Objective To investigate vaccine hesitancy leading to underimmunization and a measles outbreak in Rwanda and to develop a conceptual, community-level model of behavioural factors.Methods Local 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.Findings A 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.Conclusion The 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.

a Research Center for Access-to-Medicines, Naamsestraat 69, 3000 Leuven, Belgium.b East African Community Regional Centre of Excellence for Vaccines, Immunization and Health Supply Chain Management, University of Rwanda, Kigali, Rwanda.c System Dynamics Group, University of Bergen, Bergen, Norway.d Leuven University Vaccinology Center, KU Leuven, Leuven, Belgium.e Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Cambridge, United States of America.Correspondence to Catherine Decouttere (email: catherine.decouttere@ kuleuven .be).(Submitted: 31 December 2020 – Revised version received: 5 August 2021 – Accepted: 5 August 2021 – Published online: 28 September 2021 )

Insights into vaccine hesitancy from systems thinking, RwandaCatherine Decouttere,a Stany Banzimana,b Pål Davidsen,c Carla Van Riet,a Corinne Vandermeulen,d Elizabeth Mason,e Mohammad S Jalalie & Nico Vandaelea

784 Bull World Health Organ 2021;99:783–794D| doi: http://dx.doi.org/10.2471/BLT.20.285258

ResearchVaccine hesitancy mechanisms, Rwanda Catherine Decouttere et al.

in both a rural community and a peri-urban community between 2018 and 2020 and derived a conceptual model of vaccine hesitancy to assist in the design of sustainable interventions.

MethodsOur study design was based on WHO’s framework for health system building blocks and an already published im-munization system diagram (Fig. 1).25,26 In analysing vaccine uptake, we applied systems thinking and behavioural frameworks such as the 3Cs framework and the behavioural drivers theory.8,9,26–31 First, we assessed how underimmu-nization was influenced by the three so-called immunization service flows: (i) the vaccinee (child); (ii) the health-care workforce (nurse); and (iii) vaccine availability (vaccine). Second, we con-ducted in-depth interviews with health centre staff and collected secondary data (e.g. on vaccine orders, invento-ries and disease outbreaks). Based on our findings, we interviewed children’s

caregivers to understand local factors influencing vaccine hesitancy. Then, we used the 3Cs framework to categorize factors reported by caregivers and health centre staff.6 Finally, we derived causal relationships between behavioural drivers, vaccination intent and vacci-nation uptake by analysing the vaccine hesitancy factors identified and present these relationships in causal loop dia-grams. These diagrams are helpful for understanding complex systems and for developing interventions.29,30 All causal relationships in the causal loop diagrams and vaccine hesitancy factors were vali-dated and explained during additional discussions with health centre staff.

Participants

We interviewed 11 vaccinators and staff of the Expanded Programme on Immu-nization at three district hospitals, six health centres in a peri-urban setting in Kicukiro District, Kigali Province and five health centres in a rural setting in Ngororero District, Western Province. Additional details are available from

the data repository.32 At the community level, we interviewed caregivers at two health centres: one in rural Ramba in Ngororero District, where there was a measles outbreak in 2019, and one in Gahanga in the Kicukiro District. After a measles outbreak in July 2019, one of the Ramba health centre’s outreach posts became the Sovu health centre to be closer to people in the catchment area. Although these two locations share the same climate, epidemiologi-cal characteristics and health systems, they have different geographical and socioeconomic characteristics (Table 1). We attended two vaccination sessions at health centres and one outreach vac-cination session in both communities. Each caregiver present was invited to participate in the study (i.e. a conve-nience sample) by having a face-to-face interview in or near the session waiting room. After the purpose of the research was explained, 161 caregivers partici-pated: they were predominantly female and included both experienced mothers and mothers of firstborns.

Fig. 1. Immunization system diagram

R1

Population health status

Vaccine distribution

–

+ Outbreak response immunization

R: Reinforcing loop B: Balancing loop

R3

R2

R4

B2

B1

+

+

+

+

+

+

+

++ +

++

+

Vaccine supply

VaccinationImmunization

plan

Population well-being

Planned immunization Emergency immunization

Workforce and infrastructure

Surveillance and response

Population at risk

Morbidity and mortality

Outbreak

–=

=

=

==

+

+ Positive effect – Negative effect = Time delay in effect

+

+

Notes: The immunization system diagram is a high-level conceptual model of a national immunization system that was developed to engage stakeholders in immunization system assessment and sustainable redesign.25 The left side illustrates planned immunization (i.e. routine immunization and planned immunization campaigns) guided by a national immunization plan, and the right side illustrates emergency immunization (i.e. immunization in response to disease outbreaks). Loops R1 to R4 are reinforcing feedback loops that cause change in the same direction and loops B1 and B2 are balancing loops that cause change in the opposite direction. See Decouttere et al. for more information.25 The focal point of the immunization system diagram is vaccination and all efforts in the system are geared towards service delivery. Vaccination depends on three fundamental so-called flows that need to be synchronized at every vaccination session: (i) child (represented in the diagram by population well-being); (ii) nurse (represented by workforce and infrastructure); and (iii) vaccine (represented by vaccine distribution). Successful vaccination leads to better population health status, although only after a delay. From population health status, there are several loops that affect both planned and emergency immunization, but in different ways.

785Bull World Health Organ 2021;99:783–794D| doi: http://dx.doi.org/10.2471/BLT.20.285258

ResearchVaccine hesitancy mechanisms, RwandaCatherine Decouttere et al.

Data collection and analysis

In-depth discussions were conducted with staff at the 11 health centres (data repository)32 between September 2018 and November 2019 by three senior re-searchers and between December 2019 and February 2020 by one researcher. Discussions lasted 60 to 120 minutes and followed a topic guide (more details available in the data repository).32 Four researchers analysed data in field notes and photographed documents.

After one day’s training, six Rwan-dan data collectors conducted semis-tructured interviews with caregivers in November 2020 (data repository).32 Conversations lasting 7 to 12 minutes were held in Kinyarwanda, translated into English by the interviewer and later discussed with a supervisor and the research team to reach a consensus on interpretation. Then, two researchers analysed factors associated with vac-cine hesitancy using Excel (Microsoft Corporation, Redmond, United States of America) and four researchers clas-sified these factors. One researcher held additional discussions with health centre staff between April and Decem-ber 2020 to validate the findings (data repository).32

Three researchers used the main underlying mechanisms of vaccine hesitancy identified by the analysis to construct causal loop diagrams, which illustrate the interconnections between different factors and show feedback loops. The feedback loops can be ei-ther reinforcing (i.e. cause change in the same direction) or balancing (i.e. cause change in the opposite direction). The study was approved by the Rwanda National Ethics Committee (No. 195/RNEC/2019) and is reported according to consolidated criteria for reporting qualitative research.34

ResultsDuring data collection at the 11 health centres, we found no evidence of vac-cine stock-outs in 2018 or 2019. More-over, there were no human capacity limitations that resulted in immuniza-tion services being unavailable and national immunization coverage rates were above 90%. However, measles outbreaks occurred because of a lack of timely immunization. The suspected cause was reluctant vaccine uptake rather than limited vaccine availability.

Vaccine hesitancy

Service providers’ perspective

Interviews with Expanded Programme on Immunization staff at the Ramba and Sovu health centres, the Gahanga health centre and nine neighbouring health centres revealed contextual and behavioural factors that contributed to vaccine hesitancy. These factors were categorized according to the 3Cs frame-work (i.e. confidence, complacency and convenience) using a determinants matrix (Table 2; available at https:// www .who .int/ publications/ journals/ bulletin/ ).6 Vaccination service providers reported that confidence is increased by trust in immunization service delivery and that a good relationship between caregiv-ers and both nurses and CHWs is key. However, the time health centre staff could spend with each caregiver and the resulting quality of care were affected by an increased workload due to high peri-urban immigration rates of up to 10% per year, paperwork and other responsibilities.

We found that complacency was successfully reduced by: (i) organizing 6-monthly mother-and-child health weeks; (ii) regular community meet-ings (umuganda and w'ababyeyi or mothers’ evenings); (iii) educational sessions before vaccination sessions; and (iv) individual contacts between CHWs and caregivers. However, in rural settings, mothers tended to deprioritize or forget immunization of older children because of other tasks and because they had little contact with health centres in the 6-month interval between the first and second measles and rubella vaccine doses. This factor increased compla-cency and, combined with low disease surveillance in Sovu (which led to un-detected measles cases), contributed to the 2019 measles outbreak. CHWs were regarded as playing a crucial role in con-necting mothers to antenatal care and vaccination services. However, concerns were raised about the sustainability of CHW programmes.

With regard to convenience, the availability of immunization services

Table 1. Characteristics of two participating communities, study of vaccine hesitancy, Rwanda, 2018–2020

Characteristic Community

Ramba and Sovua Gahanga

Geographical context Rural community, hilly and remote landscape, limited road infrastructure and long distances to the health centre (i.e. more than 5 km or 2 hours travel time)

Peri-urban community with relatively short distances to the health centre (i.e. less than 5 km or 2 hours travel time)

Socioeconomic context

22% of the population live in extreme poverty,33 and many men are employed in coltan mining

9% of the population live in extreme poverty,33 and the affordability of transport is less problematic than in Ramba or Sovu

Location of local district hospital

Kabaya, Ngororero District, Western Province

Masaka, Kicukiro District, city of Kigali

Population 64 000 (50% Ramba health centre and 50% Sovu health centre)

67 000

Weekly vaccination sessions at fixed locations or outreach posts

2–4 at the Ramba health centre and 1–3 at the Sovu health centre (since 1 January 2020)

1–2 (fewer outreach services due to shorter distances and more affordable transport)

Measles outbreak since 2018

July 2019 in the Sovu catchment area

None

Migration No significant in or out migration

Increasing number of people settling in the area as they flee Kigali’s city centre where property prices are continuously increasing. Some clients visited health centres other than the one they were assigned to

a After a measles outbreak in July 2019 at one of the Ramba health centre’s outreach posts, that post became the Sovu health centre to be closer to people in the catchment area.

https://www.who.int/publications/journals/bulletin/




Tabl

e 3.

Ca

regi

vers

’ com

men

ts o

n fa

ctor

s affe

ctin

g va

ccin

e he

sitan

cy, R

wan

da, 2

018–

2020

Fact

or a

ffect

ing

vacc

ine

hesit

ancy

a

Sele

cted

com

men

ts o

n fa

ctor

by c

areg

iver

sb,c,d

,e

Rura

l hea

lth ce

ntre

s in

Ram

ba a

nd Su

vof (n

= 74

)Pe

ri-ur

ban

heal

th ce

ntre

in G

ahan

gag (n

= 87

)

Confi

denc

e

Tr

ust i

n th

e eff

ectiv

enes

s and

sa

fety

of v

acci

nes a

nd in

thei

r m

anuf

actu

rers

Posit

ive:

(i) a

ll re

spon

dent

s wer

e ha

ppy

to v

acci

nate

thei

r chi

ld a

s it p

rote

cts t

he c

hild

aga

inst

dise

ase

(of

cour

se, s

elec

tion

bias

mus

t be

cons

ider

ed h

ere

as c

areg

iver

s at v

acci

natio

n se

ssio

ns w

ere

inte

rvie

wed

. H

owev

er, r

espo

nden

ts m

entio

ned

that

, “not

hing

cou

ld st

op m

e to

com

e to

the

serv

ice”

or c

alle

d th

e se

rvic

es “a

ble

ssin

g,” w

hich

show

ed st

rong

mot

ivat

ion

and

ampl

e co

nfide

nce)

; and

(ii)

hesit

ancy

abo

ut

vacc

ines

from

spec

ific

man

ufac

ture

rs w

as n

ot o

bser

ved

or su

spec

ted

as n

o re

spon

dent

men

tione

d th

e na

me

of a

vac

cine

– th

ey re

ferre

d to

the

vacc

ine

acco

rdin

g to

the

time

at w

hich

it n

eede

d to

be

adm

inist

ered

(e.g

. “va

ccin

e fo

r 2.5

mon

ths”

)

Posit

ive:

hes

itanc

y ab

out v

acci

nes f

rom

spec

ific

man

ufac

ture

rs w

as n

ot o

bser

ved

or su

spec

ted

as n

o re

spon

dent

men

tione

d th

e na

me

of a

vac

cine

– th

ey re

ferre

d to

the

vacc

ine

acco

rdin

g to

the

time

at w

hich

it n

eede

d to

be

adm

inist

ered

(e.g

. “v

acci

ne fo

r 2.

5 m

onth

s”)

Trus

t in,

and

per

sona

l exp

erie

nce

of, t

he h

ealth

syst

em a

nd h

ealth

pr

ofes

siona

ls

Posit

ive:

(i) h

ealth

cen

tre st

aff (m

ostly

nur

ses a

nd v

acci

nato

rs) a

re se

en a

s a g

ood

sour

ce o

f inf

orm

atio

n (4

0 re

spon

dent

s) a

nd a

re c

onta

cted

to d

iscus

s que

stio

ns o

n va

ccin

atio

n (2

9 re

spon

dent

s); a

nd

(ii) r

espo

nden

ts m

entio

ned

that

get

ting

info

rmat

ion

on o

ther

hea

lth to

pics

(e.g

. stu

ntin

g) d

urin

g th

e va

ccin

atio

n se

ssio

ns a

nd re

ceiv

ing

shish

a ki

bond

o (i.

e. p

orrid

ge) w

ere

addi

tiona

l ben

efits

Posit

ive:

hea

lth c

entre

staff

(mos

tly n

urse

s and

vac

cina

tors

) mos

t fre

quen

tly

men

tione

d as

a so

urce

of i

nfor

mat

ion

(69

resp

onde

nts)

and

as a

con

tact

for

disc

ussin

g qu

estio

ns (5

5 re

spon

dent

s).

Neg

ativ

e: so

me

mot

hers

had

neg

ativ

e ex

perie

nces

whe

n th

eir c

hild

was

not

gi

ven

the

vacc

ine

(e.g

. the

y w

ere

sent

hom

e be

caus

e th

ey w

ere

late

or b

ecau

se a

m

ultid

ose

vial

cou

ld n

ot b

e op

ened

) or t

hey

rece

ived

aw

fine

(e.g

. for

bei

ng la

te,

not h

avin

g th

eir c

hild

vac

cina

ted

or n

ot re

-eng

agin

g w

ith th

e va

ccin

atio

n sy

stem

af

ter a

hom

e de

liver

y)Co

mpl

acen

cy

Co

mm

unic

atio

n an

d m

edia

en

viro

nmen

tN

eutra

l: (i)

radi

o is

still

a so

urce

of i

nfor

mat

ion

on v

acci

natio

n se

rvic

es (3

1 re

spon

dent

s); (

ii) g

over

nmen

t ca

mpa

ign

mat

eria

ls (e

.g. fl

yers

) wer

e m

entio

ned

less

ofte

n as

a so

urce

of i

nfor

mat

ion

(2 re

spon

dent

s);

and

(iii)

inte

rest

ingl

y, th

e va

ccin

atio

n ca

rd w

as a

lso e

xplic

itly

men

tione

d as

a so

urce

of i

nfor

mat

ion

(10

resp

onde

nts)

Neu

tral:

(i) ra

dio

is st

ill a

sour

ce o

f inf

orm

atio

n on

vac

cina

tion

serv

ices

(35

resp

onde

nts)

; and

(ii)

gove

rnm

ent c

ampa

ign

mat

eria

ls (e

.g. fl

yers

) wer

e fre

quen

tly m

entio

ned

as a

sour

ce o

f inf

orm

atio

n (2

0 re

spon

dent

s), a

s wer

e va

ccin

atio

n ca

rds (

6 re

spon

dent

s)In

fluen

tial l

eade

rs, i

mm

uniz

atio

n pr

ogra

mm

e ga

teke

eper

s and

va

ccin

atio

n lo

bbie

s

Posit

ive:

no

care

give

rs m

entio

ned

loca

l lea

ders

as a

neg

ativ

e in

fluen

ce (o

ne re

spon

dent

repo

rted

how

th

e lo

cal l

eade

r goe

s aro

und

the

villa

ge w

ith a

loud

spea

ker t

o gi

ve in

form

atio

n ab

out v

acci

natio

n an

d ot

her a

ctiv

ities

)

Non

e

Hist

oric

al in

fluen

ces

Posit

ive:

mea

sles o

utbr

eak

in 2

019

incr

ease

d th

e nu

mbe

r of v

isibl

e ca

ses

Non

eRe

ligio

n, c

ultu

re, g

ende

r and

so

cioe

cono

mic

fact

ors

Posit

ive:

resp

onde

nts m

entio

ned

that

, whe

n th

ey a

re si

ck, t

here

are

peo

ple

in th

e co

mm

unity

(e.g

. hu

sban

d, C

HW

or n

eigh

bour

) who

can

take

the

child

for v

acci

natio

n (i.

e. c

omm

unity

eng

agem

ent).

N

egat

ive:

(i) c

areg

iver

s men

tione

d th

at a

few

car

egiv

ers d

o no

t brin

g th

eir c

hild

ren

to th

e va

ccin

atio

n se

ssio

n, d

escr

ibin

g th

em a

s “ca

rele

ss” (

3 re

spon

dent

s) o

r “bu

sy w

ith li

fe” (

1 re

spon

dent

); an

d (ii

) fam

ily

confl

ict (

1 re

spon

dent

) and

chi

ldre

n w

ho c

ry d

urin

g th

e ni

ght a

fter v

acci

natio

n (1

resp

onde

nt) w

ere

men

tione

d as

reas

ons f

or n

ot a

ttend

ing

vacc

inat

ion

Posit

ive:

som

e re

spon

dent

s men

tione

d th

at b

eing

sick

was

a b

arrie

r (4

resp

onde

nts)

but

oth

ers (

4 re

spon

dent

s) sa

id th

at, e

ven

whe

n th

ey a

re si

ck, t

here

ar

e pe

ople

in th

e co

mm

unity

(e.g

. hus

band

, CH

W o

r nei

ghbo

ur) w

ho c

an ta

ke

the

child

for v

acci

natio

n (i.

e. c

omm

unity

eng

agem

ent).

N

egat

ive:

som

e ca

regi

vers

said

that

oth

ers m

issed

app

oint

men

ts d

ue to

“c

arel

essn

ess”

(11

resp

onde

nts)

, wor

k (2

resp

onde

nts)

or g

ivin

g bi

rth

at h

ome

(6 re

spon

dent

s) b

ut th

ey o

ften

belie

ved

they

wou

ld c

ome

late

r (e.

g. a

fter a

visi

t fro

m a

CH

W)

(contin

ues.

. .)



Fact

or a

ffect

ing

vacc

ine

hesit

ancy

a

Sele

cted

com

men

ts o

n fa

ctor

by c

areg

iver

sb,c,d

,e

Rura

l hea

lth ce

ntre

s in

Ram

ba a

nd Su

vof (n

= 74

)Pe

ri-ur

ban

heal

th ce

ntre

in G

ahan

gag (n

= 87

)

Know

ledg

e an

d aw

aren

ess

Posit

ive:

(i) C

HW

s wer

e m

entio

ned

mos

t fre

quen

tly a

s a so

urce

of i

nfor

mat

ion

on v

acci

natio

n se

rvic

es

(67

resp

onde

nts)

and

as a

con

tact

for a

skin

g qu

estio

ns a

bout

serv

ices

(70

resp

onde

nts)

but

they

wer

e al

so th

ough

t im

port

ant f

or c

omm

unity

mob

iliza

tion

and

follo

w-u

p (4

resp

onde

nts)

; (ii)

CH

W fo

llow

-up

was

exp

licitl

y m

entio

ned

as h

avin

g im

prov

ed o

ver t

he y

ears

(3 re

spon

dent

s) –

“In

the

past

, you

cou

ld

even

not

fini

sh a

ll va

ccin

es/a

ppoi

ntm

ents

and

ther

e w

as n

o on

e to

follo

w-u

p on

you

but

if y

ou d

o no

t co

me

as p

er y

our a

ppoi

ntm

ent i

n th

ese

days

, a C

HW

will

reac

h ou

t to

you

and

ask

why

you

did

not

go

for v

acci

natio

n an

d ad

vise

you

on

how

to c

atch

up”

; and

(iii)

oth

er c

omm

unity

mem

bers

(mos

tly o

ther

m

othe

rs a

nd n

eigh

bour

s) w

ere

frequ

ently

men

tione

d as

sour

ces o

f inf

orm

atio

n on

vac

cina

tion

serv

ices

(1

6 re

spon

dent

s)

Posit

ive:

(i) r

espo

nden

ts m

entio

ned

that

com

mun

ity m

embe

rs w

ere

awar

e of

th

e im

port

ance

of v

acci

natio

n be

caus

e of

com

mun

ity m

obili

zatio

n, in

volv

ing,

for

exam

ple,

CH

Ws a

nd c

ampa

igns

; and

(ii)

CHW

s wer

e m

entio

ned

as th

e se

cond

m

ost f

requ

ent s

ourc

e of

info

rmat

ion

on v

acci

natio

n se

rvic

es (4

5 re

spon

dent

s)

and

as a

con

tact

for a

skin

g qu

estio

ns a

bout

thes

e se

rvic

es (4

4 re

spon

dent

s)

Perc

eive

d ris

ks a

nd b

enefi

tsPo

sitiv

e: (i

) the

nee

d fo

r dise

ase

prev

entio

n w

as st

reng

then

ed b

y kn

owle

dge

of c

ases

of i

llnes

s or d

eath

du

e to

vac

cine

-pre

vent

able

dise

ases

(25

resp

onde

nts)

; and

(ii)

all r

espo

nden

ts w

ere

high

ly m

otiv

ated

to

atte

nd v

acci

natio

n se

ssio

ns b

y th

eir d

esire

to p

reve

nt d

iseas

e or

ens

ure

thei

r chi

ldre

n w

ill g

row

up

to b

e he

alth

y

Posit

ive:

in a

dditi

on to

thei

r rol

e in

pre

vent

ing

dise

ase,

vac

cine

s wer

e tru

sted

be

caus

e th

ey h

ad h

ad n

o ne

gativ

e eff

ects

so fa

r (7

resp

onde

nts)

. N

egat

ive:

(i) f

ear o

f adv

erse

effe

cts f

ollo

win

g im

mun

izat

ion

(2 re

spon

dent

s); a

nd

(ii) m

ost r

espo

nden

ts d

id n

ot k

now

of c

ases

of i

llnes

s or d

eath

due

to v

acci

ne-

prev

enta

ble

dise

ases

– k

now

n ca

ses (

7 re

spon

dent

s) w

ere

mos

tly p

olio

or

mea

sles,

ofte

n in

old

er p

eopl

eIm

mun

izat

ion

as a

soci

al n

orm

Posit

ive:

resp

onde

nts w

ho d

id n

ot k

now

of a

ny c

ases

of i

llnes

s or d

eath

due

to v

acci

ne-p

reve

ntab

le

dise

ases

(38

resp

onde

nts)

men

tione

d th

at th

e co

mm

unity

and

thei

r par

ents

kne

w th

e im

port

ance

of

vacc

ines

for p

rote

ctin

g ch

ildre

n; (i

i) va

ccin

atio

n se

emed

to b

e st

anda

rd (e

.g. “e

very

kid

is v

acci

nate

d in

th

e co

mm

unity

”); a

nd (i

ii) v

acci

natio

n w

as fr

eque

ntly

end

orse

d by

com

mun

ity m

embe

rs, s

uch

as fr

iend

s an

d fa

mily

Non

e

Conv

enie

nce

Avai

labi

lity

of th

e im

mun

izat

ion

serv

ice

(incl

udin

g va

ccin

e av

aila

bilit

y)

Posit

ive:

(i) o

nly

one

mot

her m

entio

ned

the

avai

labi

lity

of v

acci

nes a

s an

expl

icit

reas

on fo

r com

ing

to

the

vacc

inat

ion

sess

ion;

and

(ii)

stoc

k-ou

ts w

ere

not m

entio

ned

as a

bar

rier.

Neg

ativ

e: n

ot a

ll va

ccin

es w

ere

avai

labl

e at

out

reac

h po

sts (

one

resp

onde

nt sa

id th

at th

e va

ccin

e gi

ven

whe

n th

e ch

ild is

15

mon

ths o

f age

was

not

ava

ilabl

e)

Neg

ativ

e: c

areg

iver

s can

be

sent

aw

ay if

they

do

not h

ave

an a

ppoi

ntm

ent,

are

late

or i

f the

des

ired

vacc

ine

or a

ntig

en is

not

offe

red

that

day

, for

exa

mpl

e, to

sa

ve m

ultid

ose

vial

s

Affor

dabi

lity

of th

e im

mun

izat

ion

serv

ice

Neg

ativ

e: (i

) mor

e fin

anci

al su

ppor

t req

uest

ed (4

resp

onde

nts)

; and

(ii)

rew

ard

for b

eing

fully

vac

cina

ted

requ

este

d (1

resp

onde

nt)

Neg

ativ

e: c

ost o

f tra

nspo

rt is

a b

arrie

r (3

resp

onde

nts)

Geo

grap

hica

l acc

essib

ility

Neg

ativ

e: (i

) roa

d to

the

heal

th c

entre

is b

ad a

nd h

eavy

rain

fall

mak

es it

diffi

cult

and

risky

to a

cces

s the

va

ccin

atio

n se

rvic

e (1

2 re

spon

dent

s); (

ii) d

istan

ce w

as m

entio

ned

as a

bar

rier o

r as a

pro

blem

that

mus

t be

tack

led

(6 re

spon

dent

s), a

lthou

gh th

e ne

w h

ealth

cen

tre a

t Sov

u an

d ou

treac

h im

prov

ed th

is fo

r so

me

mot

hers

(5 re

spon

dent

s); (

iii) o

ne m

othe

r sai

d th

at o

utre

ach

post

s sho

uld

be k

ept o

pen

beca

use

they

wer

e cl

osed

for a

whi

le; a

nd (i

v) o

ne m

othe

r men

tione

d th

at v

acci

natio

n se

rvic

es w

ere

clos

e, th

anks

to

out

reac

h, b

ut th

ey st

ill n

eede

d to

wal

k fo

r mor

e th

an a

n ho

ur to

all

othe

r ser

vice

s (e.

g. to

giv

e bi

rth)

Posit

ive:

vac

cina

tion

sess

ions

wer

e ea

sy to

reac

h an

d tra

vel t

imes

wer

e sh

ort b

ut

som

e m

othe

rs st

ill re

ques

ted

addi

tiona

l out

reac

h (5

resp

onde

nts)

. N

egat

ive:

hea

vy ra

infa

ll m

akes

it d

ifficu

lt to

atte

nd (1

5 re

spon

dent

s)

Abili

ty to

und

erst

and

(i.e.

lang

uage

an

d he

alth

lite

racy

)Po

sitiv

e: o

ne m

othe

r men

tione

d sh

e ca

nnot

read

or w

rite

and

asks

fam

ily m

embe

rs o

r nei

ghbo

urs t

o re

ad th

e da

ta o

n th

e va

ccin

atio

n ca

rd.

Neg

ativ

e: fe

ar o

f bei

ng fi

ned

for a

non

-inst

itutio

nal b

irth

desp

ite th

e fin

e no

lo

nger

exi

stin

g (1

resp

onde

nt)

(. . .continued)

(contin

ues.

. .)



was negatively impacted by the supply of measles and rubella vaccine being limited outside of health centres due to a desire to reduce wastage of multi-dose vials. In addition, poor families, particularly in rural areas, were unable to attend sessions at health centres because of travel costs, distance, safety or the time required. In peri-urban settings and at district and central levels, the efficiency of, and the level of attendance at, outreach services were reported to benefit from the support of CHWs. As well as forgetting the second vaccine dose at 15 months, experienced mothers associated the dispensing of mosquito nets at 9 months (at the time of the first dose) with the end of childhood immunization, even after the second dose had been introduced. The main factor mentioned by Expanded Programme on Immunization and peri-urban health centre staff as having a negative effect on convenience was a long waiting time. In rural settings, time-saving strategies such as holding vaccination sessions on market days were regarded as having a positive impact on convenience and also on the provision of nutritional and family planning services. Finally, interviewees from all levels and settings said that paper-based data management made it difficult to monitor late immunizations and drop-outs (i.e. vaccine defaulters).

Caregivers’ perspective

Factors associated with vaccine hesitan-cy reported in interviews with caregivers in Ramba, Sovu and Gahanga were also categorized using the 3Cs framework (Table 3). With regard to confidence, caregivers reported no concerns about vaccine quality and trusted vaccines. Additionally, in rural settings, trust was reported to stem from respect for providers, including nurses and CHWs. CHWs were more often reported as a source of information in rural than in peri-urban settings. The impact of gov-ernment information campaigns seemed greater in peri-urban settings.

With regard to complacency, caregiv-ers did not mention misinformation on social media in either setting. Carelessness and forgetting were considered to be the main reasons for underimmunization, particularly when mothers had older chil-dren, more tasks and different priorities.

Factors affecting convenience var-ied considerably between rural and peri-urban settings, with differences in travel Fa

ctor

affe

ctin

g va

ccin

e he

sitan

cya

Sele

cted

com

men

ts o

n fa

ctor

by c

areg

iver

sb,c,d

,e

Rura

l hea

lth ce

ntre

s in

Ram

ba a

nd Su

vof (n

= 74

)Pe

ri-ur

ban

heal

th ce

ntre

in G

ahan

gag (n

= 87

)

Qua

lity

of th

e se

rvic

e (p

erce

ived

or

real

)Po

sitiv

e: th

e m

ajor

ity o

f car

egiv

ers w

ere

satis

fied

with

the

curre

nt se

rvic

e an

d di

d no

t sug

gest

cha

nges

or

add

ition

s (41

resp

onde

nts)

. N

eutra

l: su

gges

tions

for i

mpr

ovem

ents

rela

ted

to o

ther

serv

ices

, suc

h as

pro

vidi

ng v

itam

ins (

1 re

spon

dent

) and

pro

vidi

ng sh

isha

kibo

ndo

(por

ridge

) to

all c

hild

ren

and

not o

nly

to so

me,

as t

his i

s pe

rcei

ved

as u

nfai

r (4

resp

onde

nts)

. One

resp

onde

nt sa

id: “

Due

to fa

mily

pla

nnin

g, re

cent

dev

elop

men

t an

d se

nsiti

zatio

n, th

ose

who

did

not

resp

ect f

amily

pla

nnin

g an

d ke

pt g

ivin

g bi

rth

or d

eliv

erin

g ar

e al

way

s rec

eivi

ng fo

rtifi

ed fo

ods o

r foo

d su

pple

men

ts w

hile

, for

us w

ho re

spec

ted

it, a

re so

meh

ow

puni

shed

and

do

not g

et a

cces

s to

food

supp

lem

ents

and

yet

we

still

hav

e ch

ildre

n. O

ur w

ish a

nd

requ

est i

s to

chan

ge th

is de

cisio

n an

d gi

ve fo

rtifi

ed fo

ods t

o al

l of u

s ins

tead

of p

unish

ing

us”

Non

e

Conv

enie

nt ti

me

(incl

udin

g w

aitin

g tim

e), p

lace

and

cul

tura

l con

text

Posit

ive:

a d

esire

to re

spec

t the

giv

en a

ppoi

ntm

ent i

s the

seco

nd m

ost f

requ

ent r

easo

n fo

r atte

ndin

g a

spec

ific

sess

ion

(41

resp

onde

nts)

afte

r the

des

ire to

“pro

tect

chi

ldre

n ag

ains

t dise

ases

,” whi

ch su

gges

ts

that

the

appo

intm

ent s

yste

m, a

ided

by

vacc

inat

ion

card

s, is

effec

tive.

N

egat

ive:

(i) c

lean

wat

er, e

lect

ricity

or b

oth

requ

este

d at

the

heal

th c

entre

(2 re

spon

dent

s); (

ii) lo

ng

wai

ting

times

(2 re

spon

dent

s); a

nd (i

ii) th

e ne

ed to

redu

ce w

aitin

g tim

es c

ompa

red

with

pre

viou

s se

ssio

ns (2

resp

onde

nts)

Neg

ativ

e: (i

) lon

g w

aitin

g tim

e du

e to

too

few

nur

ses w

as a

big

issu

e (4

2 re

spon

dent

s); (

ii) a

s a re

sult,

the

wai

ting

room

was

cro

wde

d an

d pe

ople

had

to

wai

t out

side;

and

(iii)

one

resp

onde

nt su

gges

ted

that

the

mor

ning

hou

rs a

re

bette

r as i

t is l

ess h

ot to

wal

k w

ith a

chi

ld to

the

heal

th c

entre

Des

ign

of v

acci

natio

n pr

ogra

mm

e an

d va

ccin

atio

n sc

hedu

leN

eutra

l: m

othe

rs w

ith m

ore

than

one

chi

ld m

entio

ned

that

the

vacc

inat

ion

sche

dule

and

vac

cine

s had

ch

ange

d sin

ce th

ey h

ad th

eir fi

rst c

hild

(e.g

. an

extra

vac

cine

is n

eede

d w

hen

the

child

is 1

5 m

onth

s old

an

d tw

o or

thre

e in

ject

ions

are

requ

ired

inst

ead

of o

ne o

r tw

o)

Non

e

CHW

: com

mun

ity h

ealth

wor

ker.

a Fac

tors

wer

e ca

tego

rized

usin

g th

e 3C

s fra

mew

ork

as re

late

d to

con

fiden

ce, c

ompl

acen

cy o

r con

veni

ence

.8

b Com

men

ts w

ere

clas

sified

as p

ositi

ve, n

eutra

l or n

egat

ive

with

rega

rd to

thei

r im

plic

atio

ns fo

r vac

cine

upt

ake.

c The

num

bers

in th

e ta

ble

refe

r to

the

num

ber o

f int

ervi

ewee

s who

agr

eed

with

the

com

men

t.d C

hild

ren’s

car

egiv

ers w

ere

inte

rvie

wed

dur

ing

vacc

inat

ion

sess

ions

at h

ealth

cen

tres a

nd o

utre

ach

post

s in

two

com

mun

ities

.e D

etai

ls of

whi

ch in

terv

iew

ees m

ade

each

com

men

t are

ava

ilabl

e fro

m th

e da

ta re

posit

ory.32

f The

Ram

ba h

ealth

cen

tre is

in N

goro

rero

Dist

rict.

Afte

r a m

easle

s out

brea

k in

201

9, o

ne o

f the

hea

lth c

entre

’s ou

treac

h po

sts b

ecam

e th

e So

vu h

ealth

cen

tre.

g The

Gah

anga

hea

lth c

entre

is in

the

Kicu

kiro

Dist

rict o

f the

Mun

icip

ality

of K

igal

i.

(. . .continued)



distances and waiting times. In the rainy season, travelling safely with young chil-dren was complicated in rural areas and immunization was delayed; some people relied completely on outreach services.

Comparing perspectives

Both service providers and caregivers largely agreed on the strengths of the vac-cination programme but identified differ-ent challenges (Box 1, based on Table 2 and Table 3). By considering caregivers’ insights, immunization providers were able to obtain a broader perspective on their services, which in turn provided a basis for designing future interventions. For example, the introduction of an ef-ficient digital data management system could help tackle the multiple challenges perceived by immunization providers while maintaining an appointment sys-tem well regarded by caregivers.

Causal loop diagrams

The causal relationships between the main factors affecting vaccine hesitancy identified in interviews with vaccination service providers and caregivers are il-lustrated in three causal loop diagrams in Fig. 2 (available at https:// www .who .int/ publications/ journals/ bulletin/), for confidence, complacency and con-venience, respectively. Fig. 3, which is a composite of these three diagrams, indicates that vaccine uptake is governed by three key factors: (i) trust in vaccina-tion; (ii) community engagement; and (iii) access to vaccination. As vaccine uptake evolves, six feedback loops are activated (Fig. 3): three balancing B loops and three reinforcing R loops that can increase or decrease trust, engage-ment or access. These loops illustrate the dynamic nature of the system. The same factors and loops were identified in both rural and peri-urban settings but their relative impact on vaccination uptake differed. For example, in rural settings, access to vaccinations was reduced by a lack of outreach services and information campaigns, whereas, in peri-urban settings, workload pres-sure on the immunization system had a negative impact on trust in vaccination.

To maintain measles vaccination coverage at the desired level of over 95%, behaviour that increases vaccine uptake, as indicated by loops in the causal loop diagram (Fig. 3), must be actively pro-moted by health interventions. For ex-

ample, government-led information and vaccination campaigns, community ad-vocacy and direct communication from CHWs during home visits all regularly boost the perceived benefit of vaccina-tion and community engagement. The disruption caused by the coronavirus disease 2019 (COVID-19) pandemic affected the 3Cs: (i) convenience was diminished because vaccination ses-sions were smaller and less accessible; (ii) confidence was reduced by height-ened pressure on the system and fear of infection at the health centre; and (iii) complacency was increased by less contact between CHWs and caregivers.

The composite causal loop dia-gram can also be used to illustrate the circumstances that led to the 2019 measles outbreak in Sovu (Fig. 4). First, community and caregiver engagement with the second measles and rubella immunization dose for children aged

15 months was low because mothers had other priorities, perceived their children as stronger due to being older, or were not aware of the second dose. Second, in the absence of outreach services, health centres did not know which children were underimmunized. Therefore, the need for an additional immunization campaign or outreach services was not recognized. The resulting outbreak trig-gered a new immunization campaign and further investigations. Eventually, a new health centre was established in the affected area, which reduced the previously underimmunized popula-tion’s dependency on both outreach services and immunization campaigns. The ongoing development of digital data management systems at health centres will support this change. In addition, CHWs can help bridge the gap between caregivers and the health system and can assist in surveillance.

Box 1. Vaccination service providers’ and caregivers’ perspectives on the strengths of, and challenges to, the measles vaccination programme in rural and peri-urban Rwanda, 2018–2020

StrengthsAll interviewees:

• CHWs provide information, mobilize caregivers and follow up vaccines;

• health centre staff provide information;

• confidence in vaccination is high;

• there is an intrinsic motivation to improve health; and

• community support.

Vaccination service providers:

• health ministry committed to supporting CHWs and mother-and-child health weeks.

Caregivers:

• vaccination cards;

• information provided by radio;

• high service quality; and

• appointments system.

ChallengesAll interviewees:

• outreach services needed for poor and hard-to-reach families.

Vaccination service providers:

• high staff turnover and workload and need for training;

• tracing of vaccine defaulters inefficient;

• outreach services for measles and rubella vaccination inadequate; and

• mothers missing the second measles and rubella vaccine dose for their children.

Caregivers:

• difficult vaccination access in the rainy season;

• long distances to health centres; and

• long waiting times.

CHW: community health worker.





Fig. 3. Composite causal loop diagram of factors affecting vaccine hesitancy, Rwanda, 2018–2020

Pressure on immunization

system

Disease incidence

–


+

+

+

+

+

+

Community engagement

Perceived vaccine benefit

Vaccination–

+ Positive effect – Negative effect

–+

++

Relationship with health centre staff

Perceived quality of vaccination service

Trust in vaccination

Perceived threat of disease

R Complacency

B Complacency

R Confidence

BConfidence

Outreach and campaign planning

Outreach and campaign need

Individual health

R Convenience

B Convenience

Access to vaccination

Health literacy and mobility

Protected population+

+

+

+

–

+

+

+

Notes: This diagram is the composite of the three causal loop diagrams in Fig. 2. Factors affecting vaccine hesitancy were categorized using the 3Cs framework as related to confidence, complacency or convenience.8 The R loops are reinforcing feedback loops that cause change in the same direction and the B loops are balancing loops that cause change in the opposite direction.

Fig. 4. Composite causal loop diagram of factors affecting vaccine hesitancy during a measles outbreak, Rwanda, 2019


system

Disease incidence

–


+

+

+

+

+

+



Vaccination–


-+

+

+





R Complacency

B Complacency

R Confidence

BConfidence



Individual health

R Convenience

B Convenience



Protected population+

+

+

+

–

+

+

+

Surveillance

Child ageing

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+

Caregiver’sother priorities

–

Communication campaign

Community health workers

Digital data management

New health centre

+

+

+

+

–+

Important factors influencing vaccination uptake Interventions introduced to decrease vaccine hesitancy

Notes: The measles outbreak occurred in the catchment area of the Ramba health centre in 2019. This diagram is an adaptation of the causal loop diagram in Fig. 3. Factors affecting vaccine hesitancy were categorized using the 3Cs framework as related to confidence, complacency or convenience.8 The R loops are reinforcing feedback loops that cause change in the same direction and the B loops are balancing loops that cause change in the opposite direction.



DiscussionOur analysis of factors influencing vac-cine hesitancy in Rwanda offers several insights. For example, trust in vaccina-tion and social cohesion are factors that can be leveraged in various settings. However, the differences we identified between rural and peri-urban settings in the ease of travel indicate that solutions for vaccine hesitancy and vaccine policy design are dependent on the setting, even for the same vaccine in the same country. Both vaccination service providers (i.e. Expanded Programme on Immunization staff and CHWs) and caregivers thought that the accessibility of vaccination ses-sions and the quality of the immunization service were important influences behind underimmunization. However, the in-sights we obtained from service providers and caregivers revealed they had differing perspectives, which provided an op-portunity for collective learning and for increasing vaccine uptake.

Some service delivery policies had unintended consequences. For instance, according to national guidelines, multi-dose vaccine vials must be used at fixed sites rather than at both outreach posts and fixed sites to reduce wastage. This policy may increase vaccine hesitancy by reducing access to, or the convenience of, vaccination for people dependent on outreach services. Moreover, in some places in Rwanda, there used to be a financial penalty if a child was not reg-istered with the vaccine system at birth. Consequently, families whose children were born at home were often deterred from visiting health centres due to mis-information that the penalty still existed. Conversely, this lasting fear of a financial penalty may incentivize some pregnant mothers to engage with vaccination.

Our findings illustrate the crucial role of community engagement in building system resilience. Causal loops can be strengthened or weakened by external elements, such as interven-tions made in response to a measles outbreak. For instance, communication within communities can be leveraged by prolonging CHW programmes, thereby enhancing social cohesion. In contrast, the COVID-19 pandemic induced the perception that health centre visits were unsafe. This perception, combined with

the temporary cancellation of commu-nity awareness activities and educational sessions at health centres, resulted in immunization being delayed until mid-August 2020. The speed at which vaccine uptake was restored after the disruption showed the resilience of the system.35,36

As outreach services are a cor-nerstone of measles immunization programmes in some populations, their sustainability will affect future immu-nization programmes. The efficiency of outreach could be increased by focusing efforts on hard-to-reach populations or by establishing temporary outreach posts during the rainy season. Depen-dency on outreach services could be reduced by opening new health-care delivery points or by providing physical or financial support to enable caregivers to travel to health centres, both of which would enhance the sustainability of the immunization system.

Our study of two settings in Rwanda revealed leverage points that cut across several factors influencing vaccine hesitancy (i.e. one specific intervention can impact multiple loops within the immunization system). For example, we found that the connecting role of CHWs was pivotal and that they could function as a high-potential leverage point because they have a direct impact on two feedback loops in Fig. 3: the balancing convenience loop (i.e. iden-tifying the need for outreach and vac-cination campaigns) and the reinforc-ing complacency loop (i.e. increasing awareness of the benefits of vaccination through home visits).25 Furthermore, the digitization of local immunization data, such as the immunization status of the population (irrespective of the point of vaccination), could guide targeted and timely preventive interventions (e.g. catch-up vaccinations in the child’s second year of life), assist in campaign planning and help trace defaulters. Nev-ertheless, the factors affecting vaccine hesitancy can change over time (e.g. in response to vaccine-hesitant social media influencers).37

Our study has limitations. First, the presence of a well-functioning vaccina-tion delivery system in Rwanda may make it more difficult to generalize our findings. Second, although we carefully selected the study settings, they were

limited in number and our findings relate to only rural and peri-urban communities. More research is needed on urban and other settings. Third, we were not able to interview caregiv-ers who are not present at vaccination sessions. However, interviewees were asked about the motivations of caregiv-ers who missed sessions. Similarly, we interviewed only CHWs and other vac-cination service providers who spoke on behalf of their teams, which may have introduced bias. Finally, the COVID-19 pandemic complicated fieldwork.

In addition to overcoming these limitations, future research could build on our insights and causal loop dia-grams to develop a human-centred, collaborative approach to identifying leverage points that could be used to design sustainable interventions for minimizing vaccine hesitancy. More-over, our systems thinking approach and factors influencing hesitancy could be integrated with initiatives like the Vaccine Confidence Project,38 which contains a tool for mapping confidence globally.12,14,39,40 ■

AcknowledgementsWe thank Christine Lee, Alan Zhang, the Expanded Programme on Immuniza-tion team in Rwanda and all participants in workshops, interviews and field visits.

Funding: This work was funded by GSK through the GSK research chair on the redesign of health care supply chains in developing countries to increase access-to-medicines, KU Leuven.

Competing interests: Stany Banzimana received a PhD scholarship funded by GSK. Catherine Decouttere was funded through a GSK research chair at KU Leuven. Corinne Vandermeulen was a principal investigator on a study for GSK unrelated to this research for which KU Leuven received a grant.



摘要从系统思维深入了解“疫苗犹豫”，卢旺达目的调查导致卢旺达免疫不足和麻疹爆发的“疫苗犹豫”，并开发一个社区层面的概念性行为因素模型。方法采用系统思维、以人为本的设计理念和行为框架，探索了卢旺达两个社区（其中一个地区最近经历了麻疹爆发）的当地免疫系统。收集的 2018 年至 2020 年数据来自：与 11 位疫苗接种服务提供者（即医院和卫生中心工作人员）的讨论；采访了卫生中心的 161 名儿童看护人员；以及与卫生中心工作人员进行的九次验证访谈。使用 3C 框架对影响“疫苗犹豫”的因素进行分类：信心感、满足度和便利性。开发了具有反馈回路的“疫苗犹豫”机制的概念模型。结果对农村和城郊环境中服务提供者和看护人员的观点进行比较，结果表明以下类似因素加强了疫苗接种：

(I) 基于与卫生中心工作人员的个人关系对疫苗和服务提供者的高度信任；(ii) 社区卫生工作者所起到的纽带作用；(iii) 强烈的社区意识。被确定为增加“疫苗犹豫”的因素（例如服务的可及性和后续随访不足）在不同的环境中以及在不同的服务提供者和看护人员之间有所差异。该概念模型可用于解释近期麻疹爆发的驱动因素，并指导提高疫苗接种率的干预措施。结论行为框架和系统思维的应用揭示了卢旺达社区的

“疫苗犹豫”机制，证明了免疫服务与护理人员的疫苗接种行为之间的相互关系。还确定了营造信心的社会结构和不同环境下影响疫苗接种的挑战。

Résumé

Analyse de l'hésitation vaccinale à l'aide de la pensée systémique au Rwanda Objectif Analyser l'hésitation vaccinale menant à une immunisation insuffisante et à une épidémie de rougeole au Rwanda, mais aussi développer un modèle conceptuel de facteurs comportementaux à l'échelle communautaire.Méthodes Nous avons examiné les systèmes d'immunisation locaux dans deux communautés rwandaises (l'une ayant récemment subi une épidémie de rougeole) en utilisant la pensée systémique, une approche centrée sur l'humain et des cadres comportementaux. Les données ont été récoltées entre 2018 et 2020 auprès de plusieurs sources: les discussions avec 11 prestataires de services liés à la vaccination (hôpitaux et centres médicaux); des entretiens avec 161 aides-soignants du département pédiatrique dans divers centres médicaux; et enfin, neuf entretiens de validation avec le personnel des centres médicaux. Nous avons classé les facteurs conditionnant l'hésitation vaccinale conformément à la règle des 3 C: confiance (confidence), sous-estimation

du danger (complacency) et commodité (convenience). Un modèle conceptuel des mécanismes d'hésitation vaccinale assorti de boucles de rétroaction a également été élaboré.Résultats D'après une comparaison entre les perspectives des prestataires de services et aides-soignants, tant en milieu rural que périurbain, des facteurs similaires renforcent la prise vaccinale: (i) un degré de confiance élevé envers les vaccins et les prestataires de services, fondé sur les relations entretenues avec le personnel des centres médicaux; (ii) le rôle d'intermédiaire joué par les agents de santé communautaires; et enfin, (iii) un fort sentiment d'appartenance à la collectivité. Les facteurs qui ont tendance à accroître l'hésitation vaccinale (parmi lesquels figurent l'accessibilité aux services et l'absence de suivi adéquat) varient entre prestataires de services et aides-soignants, ainsi que selon les milieux. Le modèle conceptuel pourrait servir à

ملخصنظرة متعمقة على التردد في تعاطي اللقاح من واقع التفكير النظامي، رواندا

يؤدي ما وهو اللقاح تعاطي في التردد عن الاستقصاء الغرض إلى نقص المناعة وتفشي مرض الحصبة في رواندا، وتطوير نموذج

مفاهيمي على مستوى المجتمع للعوامل السلوكية.الطريقة تم استكشاف أنظمة التحصين المحلية في مجتمعين روانديين (تعرض أحدهما مؤخرًا لتفشي مرض الحصبة)، باستخدام التفكير النظامي، والتصميم المرتكز على الإنسان، وأطر العمل السلوكية. مناقشات من: و2020 2018 عامي بين البيانات تجميع تم بالمستشفى العمل فريق (أي التطعيم خدمة مقدمي من 11 مع مقدمي من 161 مع شخصية ومقابلات الصحي)؛ والمركز شخصية مقابلات وتسع الصحية؛ المراكز في للأطفال الرعاية التي العوامل تم تصنيف المركز الصحي. للتحقق مع فريق عمل :3Cs عمل إطار باستخدام اللقاح تعاطي في التردد على تؤثر (Complacency)، والراحة (Confidence)، والرضا الثقة (Convenience). تم تطوير نموذج مفاهيمي لآليات التردد في

تعاطي اللقاح مع حلقات طرح التعليقات.الخدمات، ووجهات مقدمي نظر بين وجهات المقارنة إن النتائج الحضرية، وشبه الريفية المناطق من كل في الرعاية، مقدمي نظر

تعاطي نسبة من زادت قد مماثلة عوامل هناك أن أظهرت أساس على الخدمة ومقدمي اللقاحات في عالية ثقة (1) اللقاح: الدور الصحي؛ و(2) المركز فريق عمل مع الشخصية العلاقات بالانتماء (3) شعور قوي و بالمجتمع؛ الصحيين للعاملين المتصل للمجتمع. إن العوامل التي تم التوصل إلى أنها تزيد من التردد في غير والمتابعة الخدمة، على الحصول إمكانية (مثل اللقاح تعاطي الكافية)، اختلفت بين مقدمي الخدمة ومقدمي الرعاية، وفيما بين تفشي دوافع لشرح المفاهيمي النموذج استخدام يمكن المواقع. نسبة لزيادة المقررة التدخلات ولتوجيه مؤخرًا، الحصبة مرض

تعاطي اللقاح.الاستنتاج إن كل من تطبيق أطر العمل السلوكية والتفكير النظامي كشفا عن آليات التردد في تعاطي اللقاح في المجتمعات الرواندية، وسلوك التحصين خدمات بين المتبادلة العلاقة توضح والتي التطعيم لدى مقدمي الرعاية. كما تم التوصل إلى الهياكل الاجتماعية على تؤثر والتي السياق، على تعتمد التي والتحديات الثقة، لبناء

نسبة تعاطي اللقاح.



identifier les moteurs de la récente épidémie de rougeole, et orienter les actions destinées à améliorer la prise vaccinale.Conclusion L'application des cadres comportementaux et de la pensée systémique ont révélé les mécanismes qui sous-tendent l'hésitation vaccinale au sein des communautés rwandaises, et qui prouvent la

corrélation entre les services d'immunisation et le comportement des aides-soignants en la matière. Nous avons également découvert des structures sociales de restauration de la confiance ainsi que des défis qui, en fonction du contexte, ont un impact sur la prise vaccinale.

Резюме

Понимание недоверия к вакцинации на основе системного мышления, РуандаЦель Изучить недоверие к вакцинации, ведущее к недостаточной иммунизации и вспышке кори в Руанде, а также разработать концептуальную модель поведенческих факторов на общинном уровне.Методы Были изучены местные системы по иммунизации в двух руандийских общинах (одна из которых недавно пережила вспышку кори) с использованием системного мышления, дизайна, ориентированного на потребности человека, и поведенческих структур. Были собраны данные в период с 2018 по 2020 год в результате обсуждений с 11 поставщиками услуг в области вакцинации (то есть персоналом больниц и центров здравоохранения), интервью с 161 лицом, осуществляющим уход за детьми в центрах здравоохранения, и девяти оценочных интервью с персоналом центра здравоохранения. Факторы, влияющие на недоверие к вакцинации, были классифицированы с использованием «сис темы 3 фак торов» : доверие, удовлетворенность жизненной ситуацией и удобство. Была разработана концептуальная модель механизмов недоверия к вакцинации с обратной связью.Результаты Сравнение мнений поставщиков услуг и лиц, осуществляющих уход, в сельских и пригородных районах

показало, что увеличению охвата вакцинацией способствовали аналогичные факторы: (i) высокое доверие к вакцинам и поставщикам услуг, основанное на личных отношениях с персоналом центра здравоохранения; (ii) связующая роль местных медицинских работников; (iii) сильное чувство общности. Факторы, идентифицированные как растущее недоверие к вакцинации (например, доступность обслуживания и недостаточное последующее наблюдение), различались между поставщиками услуг и лицами, осуществляющими уход, а также между районами. Концептуальную модель можно использовать для объяснения причин недавней вспышки кори и для разработки мероприятий, направленных на увеличение охвата вакцинацией.Вывод Применение поведенческих структур и системного мышления выявило в руандийских общинах механизмы недоверия к вакцинации, которые демонстрируют взаимосвязь между иммунизационным обслуживанием и поведением лиц, осуществляющих уход, в отношении вакцинации. Были также определены социальные структуры, способствующие укреплению доверия, и контекстно зависимые проблемы, влияющие на охват вакцинацией.

Resumen

Reflexiones sobre la reticencia a las vacunas desde el pensamiento sistémico en RuandaObjetivo Estudiar la reticencia a las vacunas que ha causado la falta de vacunación y la aparición de un brote de sarampión en Ruanda, y desarrollar un modelo conceptual a nivel comunitario de los factores de comportamiento.Métodos Se analizaron los programas locales de vacunación en dos comunidades de Ruanda (una de las que experimentó un brote de sarampión hace poco) mediante el uso de marcos de pensamiento sistémico, de diseño centrado en el ser humano y de comportamiento. Los datos se recopilaron entre 2018 y 2020 a partir de conversaciones con 11 proveedores de servicios de vacunación (es decir, personal de hospitales y de centros sanitarios); entrevistas con 161 cuidadores de niños en centros sanitarios; y 9 entrevistas de validación con personal de centros sanitarios. Los factores que influyen en la reticencia a la vacunación se clasificaron mediante el modelo de las 3 C: confianza, complacencia y conveniencia. Asimismo, se elaboró un modelo conceptual de los mecanismos de reticencia a la vacunación que incluye ciclos de retroalimentación.Resultados Una comparación entre las perspectivas de los proveedores de servicios y de los cuidadores, tanto en entornos rurales como

periurbanos, indicó que factores similares reforzaban la adopción de las vacunas: i) la gran confianza en las vacunas y en los proveedores de servicios gracias a las relaciones personales con el personal del centro sanitario; ii) el rol de conexión de los profesionales sanitarios de la comunidad; y iii) el gran sentido de pertenencia a la comunidad. Los factores identificados que aumentan la reticencia a las vacunas (por ejemplo, la accesibilidad a los servicios y el seguimiento insuficiente) difieren entre los proveedores de servicios y los cuidadores y entre los distintos entornos. El modelo conceptual se podría utilizar para explicar los factores que influyeron en el reciente brote de sarampión y para orientar las intervenciones diseñadas con el objetivo de aumentar la adopción de vacunas.Conclusión La aplicación de marcos de comportamiento y del pensamiento sistémico reveló mecanismos de reticencia a las vacunas en las comunidades de Ruanda que evidencian la interrelación entre los servicios de vacunación y el comportamiento de vacunación de los cuidadores. También se identificaron las estructuras sociales de fomento de la confianza y los desafíos específicos del contexto que afectan a la adopción de las vacunas.

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https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

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https://www.unicef.org/mena/media/5586/file/The_Behavioural_Drivers_Model_0.pdf%20.pdf

http://dx.doi.org/10.1177/1529100618760521

http://dx.doi.org/10.1177/1529100618760521


http://dx.doi.org/10.1002/sres.2329









http://dx.doi.org/10.2105/AJPH.2005.062059





http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E

http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E

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https://wellcome.org/sites/default/files/wellcome-global-monitor-2018.pdf

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http://dx.doi.org/10.1126/science.aay6485


http://dx.doi.org/10.1126/sciimmunol.aay6125


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https://www.who.int/publications/i/item/9789241503396

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http://dx.doi.org/10.1186/s12961-016-0101-8


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http://dx.doi.org/10.1146/annurev-publhealth-031210-101222


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http://dx.doi.org/10.1186/s12913-016-1867-7

http://dx.doi.org/10.1186/s12913-016-1867-7


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http://dx.doi.org/10.6084/m9.figshare.16578242.v1

http://dx.doi.org/10.6084/m9.figshare.16578242.v1

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https://www.statistics.gov.rw/publication/poverty-mapping-report-2013-2014

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http://dx.doi.org/10.1093/intqhc/mzm042


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Bull World Health Organ 2021;99:783–794D| doi: http://dx.doi.org/10.2471/BLT.20.285258 794A


Tabl

e 2.

Va

ccin

atio

n se

rvice

pro

vide

rs’ c

omm

ents

on

fact

ors a

ffect

ing

vacc

ine

hesit

ancy

, Rw

anda

, 201

8–20

20

Fact

or a

ffect

ing

vacc

ine

hesit

ancy

a

Sele

cted

com

men

ts o

n fa

ctor

by s

ervi

ce p

rovi

ders

b

Loca

tion

of se

rvice

pro

vide

rs’ f

acili

tiesc,d

Dist

rict h

ospi

tals

(n =

3)Ru

ral h

ealth

cent

res (

n =

5)Pe

ri-ur

ban

heal

th ce

ntre

s (n

= 6)

Confi

denc

eTr

ust i

n th

e eff

ectiv

enes

s an

d sa

fety

of

vacc

ines

and

in th

eir

man

ufac

ture

rs

Posit

ive:

“vac

cine

hes

itanc

y, in

the

narro

wes

t se

nse

of tr

ust i

n th

e va

ccin

e, is

not

an

issue

in

Rwan

da”

Posit

ive:

(i) h

igh

leve

l of t

rust

in v

acci

natio

n; a

nd (i

i) on

e va

ccin

ator

saw

ver

y fe

w a

dole

scen

t girl

s who

fear

ed th

e H

PV v

acci

ne a

nd h

ad q

uest

ions

abo

ut

rum

ours

that

the

vacc

ine

wou

ld p

reve

nt p

regn

ancy

Posit

ive:

hig

h le

vel o

f tru

st in

vac

cina

tion

Trus

t in,

and

per

sona

l ex

perie

nce

of, t

he h

ealth

sy

stem

and

hea

lth

prof

essio

nals

Neu

tral:

CHW

s are

hig

hly

resp

ecte

d (m

ore

in ru

ral

than

urb

an a

reas

). N

egat

ive:

(i) h

igh

turn

over

of s

taff

at h

ealth

ce

ntre

s; (ii

) ins

uffici

ent t

rain

ing

of v

acci

nato

rs

to u

pgra

de th

eir k

now

ledg

e; (i

ii) in

suffi

cien

t in

duct

ion

for n

ewly

recr

uite

d nu

rses

and

va

ccin

ator

s; (iv

) sho

rtag

e of

vac

cina

tors

and

nu

rses

; and

(v) h

igh

vacc

inat

or w

orkl

oad

due

to

mon

itorin

g an

d pa

perw

ork

Neu

tral:

som

e ca

regi

vers

trav

el fa

r to

see

an e

xper

ienc

ed n

urse

they

kno

w

rath

er th

an a

ttend

a n

ew, c

lose

r hea

lth c

entre

. N

egat

ive:

(i) s

hort

age

of st

aff a

t hea

lth c

entre

s bec

ause

nur

ses p

refe

r to

get

jobs

at a

hos

pita

l or i

n ci

ties r

athe

r tha

n in

rura

l are

as; (

ii) in

suffi

cien

t tra

inin

g of

nur

ses i

n va

ccin

e m

anag

emen

t; an

d (ii

i) du

ring

lock

dow

n, p

eopl

e w

ere

afra

id o

f get

ting

infe

cted

with

SAR

S-Co

V-2

whe

n th

ey v

isite

d he

alth

cen

tres

Posit

ive:

con

nect

ions

with

hea

lth c

entre

s mad

e du

ring

ante

nata

l car

e an

d in

stitu

tiona

l birt

hs.

Neu

tral:

the

impa

ct o

f loc

kdow

n on

hea

lth c

entre

vi

sits w

as h

ighe

r in

rura

l are

as.

Neg

ativ

e: (i

) ins

uffici

ent t

ime

with

car

egiv

ers

beca

use

of p

aper

wor

k lo

ad; (

ii) to

o m

uch

wor

k fo

r th

e st

aff a

vaila

ble;

and

(iii)

staff

shor

tage

s a h

uge

prob

lem

Com

plac

ency

Com

mun

icat

ion

and

med

ia e

nviro

nmen

tPo

sitiv

e: m

othe

r-an

d-ch

ild h

ealth

wee

ks h

eld

ever

y 6

mon

ths

Posit

ive:

CH

Ws’

role

incr

ease

d du

ring

lock

dow

n (w

hen

they

wer

e th

e on

ly

chan

nel f

or in

form

atio

n)N

one

Influ

entia

l lea

ders

, im

mun

izat

ion

prog

ram

me

gate

keep

ers

and

vacc

inat

ion

lobb

ies

Posit

ive:

hea

lth m

inist

er su

ppor

tive

of

imm

uniz

atio

n pr

ogra

mm

e, C

HW

s and

mot

her-

and-

child

hea

lth w

eeks

Non

eN

one

Relig

ion,

cul

ture

, gen

der

and

soci

oeco

nom

ic

fact

ors

Non

ePo

sitiv

e: u

mug

anda

(i.e

. mon

thly

Rw

anda

n vo

lunt

ary

com

mun

ity m

eetin

gs

whe

re lo

cal i

ssue

s and

upd

ates

are

disc

usse

d).

Neg

ativ

e: (i

) um

ugan

da w

as te

mpo

raril

y su

spen

ded

durin

g lo

ckdo

wn;

(ii

) “m

othe

rs a

re fo

rget

ting

abou

t the

seco

nd m

easle

s dos

e”; (

iii) “

atte

ntio

n of

m

othe

r red

uces

whe

n ch

ild g

row

s up”

; (iii

) mot

hers

hav

e ot

her p

riorit

ies a

nd

post

pone

visi

ts to

hea

lth c

entre

s and

vac

cina

tion

sess

ions

, res

ultin

g in

late

im

mun

izat

ion;

(iv)

“for

gett

ing

is no

t abo

ut b

eing

unw

illin

g, b

ut th

e m

othe

r co

uldn

’t go

bec

ause

of o

ther

prio

ritie

s”; (

v) “I

wou

ld g

o to

mor

row

or n

ext

wee

k”; (

vi) s

omet

imes

the

vacc

inat

ion

sess

ion

is th

e sa

me

day

whe

n sa

larie

s fo

r 15

days

are

giv

en o

ut, s

o ca

regi

vers

can

not a

ttend

that

day

; and

(vii)

poo

r fa

mili

es w

ork

long

hou

rs a

way

from

hom

e, le

avin

g lit

tle ti

me

for c

hild

ren

Non

e

(contin

ues.

. .)

Bull World Health Organ 2021;99:783–794D| doi: http://dx.doi.org/10.2471/BLT.20.285258794B


Fact

or a

ffect

ing

vacc

ine

hesit

ancy

a

Sele

cted

com

men

ts o

n fa

ctor

by s

ervi

ce p

rovi

ders

b

Loca

tion

of se

rvice

pro

vide

rs’ f

acili

tiesc,d

Dist

rict h

ospi

tals

(n =

3)Ru

ral h

ealth

cent

res (

n =

5)Pe

ri-ur

ban

heal

th ce

ntre

s (n

= 6)

Know

ledg

e an

d aw

aren

ess

Posit

ive:

(i) C

HW

s hav

e an

impo

rtan

t rol

e in

bu

ildin

g co

mm

unity

eng

agem

ent;

(ii) C

HW

s are

tru

sted

and

hig

hly

resp

ecte

d by

the

com

mun

ity;

and

(iii)

hom

e vi

sits b

y CH

Ws a

t chi

ldbi

rth

conn

ects

mot

hers

with

hea

lth c

entre

s and

in

form

s the

m a

bout

imm

uniz

atio

n.

Neg

ativ

e: C

HW

serv

ice

may

not

be

sust

aina

ble

beca

use

repl

acin

g ag

eing

CH

Ws d

epen

ds o

n th

e m

otiv

atio

n of

the

next

gen

erat

ion

Posit

ive:

(i) 4

5- to

60-

min

ute

info

rmat

ion

sess

ions

bef

ore

vacc

inat

ion

sess

ions

at

hea

lth c

entre

s and

out

reac

h po

sts;

and

(ii) v

ery

low

per

cent

age

of p

eopl

e ha

ve li

ttle

und

erst

andi

ng o

f the

impo

rtan

ce o

f vac

cine

s. N

egat

ive:

(i) i

nfor

mat

ion

sess

ions

at f

acili

ties w

ere

susp

ende

d du

ring

lock

dow

n if

ther

e w

as in

suffi

cien

t spa

ce; (

ii) th

ere

was

a lo

ng in

terv

al w

ith

no c

onta

ct w

ith h

ealth

cen

tres b

etw

een

child

hood

vac

cina

tions

at 9

and

15

mon

ths o

f age

; and

(iii)

dur

ing

the

2019

mea

sles o

utbr

eak,

CH

Ws w

ere

not

able

to v

isit t

he w

hole

are

a to

raise

aw

aren

ess a

nd d

etec

t mea

sles c

ases

Non

e

Perc

eive

d ris

ks a

nd

bene

fits

Non

eN

egat

ive:

(i) t

he p

erce

ived

risk

of d

iseas

e w

as lo

w b

ecau

se c

ases

in th

e co

mm

unity

rem

aine

d un

dete

cted

; and

(ii)

“mea

sles c

ases

wer

e no

t det

ecte

d,

not d

iagn

osed

, and

not

med

ical

ly tr

eate

d”

Posit

ive:

“peo

ple

are

intri

nsic

ally

mot

ivat

ed fo

r va

ccin

atio

n”

Imm

uniz

atio

n as

a so

cial

no

rmPo

sitiv

e: im

mun

izat

ion

disc

usse

d as

par

t of

mon

thly

com

mun

ity m

eetin

gs (u

mug

anda

) and

m

othe

rs’ e

veni

ngs (

w'a

baby

eyi)

Non

eN

one

Conv

enie

nce

Avai

labi

lity

of th

e im

mun

izat

ion

serv

ice

Posit

ive:

CH

Ws’

role

in ra

ising

aw

aren

ess i

n th

e co

mm

unity

and

org

aniz

ing

outre

ach

serv

ices

. N

egat

ive:

hig

her v

acci

ne w

asta

ge a

t out

reac

h po

sts

Neg

ativ

e: (i

) poo

r fam

ilies

wer

e no

t abl

e to

affo

rd tr

avel

to h

ealth

cen

tres a

nd

relie

d on

out

reac

h se

rvic

es; (

ii) m

easle

s and

rube

lla v

acci

ne a

vaila

ble

only

at

heal

th c

entre

s and

not

at o

utre

ach

post

s; (ii

i) BC

G va

ccin

e av

aila

ble

only

whe

n 10

chi

ldre

n w

ere

wai

ting;

(iv)

mot

hers

that

gav

e bi

rth

som

etim

es n

eede

d to

com

e ba

ck to

the

heal

th c

entre

with

in 2

wee

ks fo

r the

BCG

vac

cine

; and

(v

) vac

cine

s in

mul

tidos

e vi

als (

e.g.

the

mea

sles a

nd ru

bella

vac

cine

) wer

e off

ered

onc

e a

wee

k w

here

as o

ther

vac

cine

s wer

e off

ered

dai

ly

Posit

ive:

(i) o

utre

ach

serv

ices

wer

e off

ered

at t

wo

sites

(2 d

ays p

er w

eek

at o

ne a

nd 1

day

per

wee

k at

th

e ot

her);

(ii)

CHW

s hel

ped

incr

ease

the

effici

ency

of

out

reac

h se

rvic

es b

y m

akin

g su

re th

e rig

ht

amou

nt o

f vac

cine

was

take

n to

out

reac

h po

sts;

and

(iii)

all v

acci

nes,

incl

udin

g th

e BC

G va

ccin

e, o

ffere

d ev

ery

day.

Neg

ativ

e: v

acci

nes i

n m

ultid

ose

vial

s (e.

g. th

e m

easle

s and

rube

lla v

acci

ne) w

ere

offer

ed o

nly

once

a

wee

k w

here

as o

ther

vac

cine

s wer

e off

ered

dai

lyAff

orda

bilit

y of

the

imm

uniz

atio

n se

rvic

eN

one

Neg

ativ

e: p

oor f

amili

es w

ere

not a

ble

to a

fford

to tr

avel

to h

ealth

cen

tres

Posit

ive:

“pov

erty

is n

ot a

reas

on fo

r not

com

ing,

ev

eryb

ody

com

es: p

oor a

nd le

ss p

oor.”

N

egat

ive:

“usu

ally

, liv

ing

cond

ition

s are

a d

river

for

drop

ping

out

”G

eogr

aphi

cal a

cces

sibili

tyN

one

Posit

ive:

“sho

rt d

istan

ce, p

eopl

e fro

m d

iffer

ent c

atch

men

t are

as a

nd d

istric

ts

com

e he

re.”

Neg

ativ

e: (i

) hea

lth c

entre

diffi

cult

to a

cces

s; an

d (ii

) hill

y ar

ea w

ith lo

ng

dist

ance

s to

heal

th c

entre

s, so

peo

ple

rely

on

outre

ach

Neg

ativ

e: re

stric

ted

acce

ss to

one

hea

lth c

entre

due

to

a la

ndsli

de

Abili

ty to

und

erst

and

(i.e.

lang

uage

and

hea

lth

liter

acy)

Neg

ativ

e: m

othe

rs so

met

imes

forg

et th

e sc

hedu

led

appo

intm

ent f

or th

e ne

xt v

acci

nes

Neg

ativ

e: (i

) con

fusio

n ab

out t

he se

cond

mea

sles a

nd ru

bella

vac

cine

dos

e fo

r ch

ildre

n ag

ed 1

5 m

onth

s bec

ause

mos

quito

net

s are

disp

ense

d w

hen

they

ar

e ag

ed 9

mon

ths;

(ii) m

othe

rs’ la

ck o

f edu

catio

n is

a re

ason

for t

he se

cond

m

easle

s and

rube

lla v

acci

ne d

ose

bein

g m

issed

; and

(iii)

som

e ca

regi

vers

are

no

t abl

e to

read

the

vacc

inat

ion

card

bec

ause

of a

lack

of e

duca

tion

Posit

ive:

app

oint

men

t sys

tem

with

car

ds is

wel

l un

ders

tood

by

care

give

rs.

Neg

ativ

e: m

isund

erst

andi

ng o

f pra

ctic

al a

nd

orga

niza

tiona

l pol

icie

s mak

es p

eopl

e fe

el

unw

elco

me

(. . .continued)

(contin

ues.

. .)

Bull World Health Organ 2021;99:783–794D| doi: http://dx.doi.org/10.2471/BLT.20.285258 794C


Fact

or a

ffect

ing

vacc

ine

hesit

ancy

a

Sele

cted

com

men

ts o

n fa

ctor

by s

ervi

ce p

rovi

ders

b

Loca

tion

of se

rvice

pro

vide

rs’ f

acili

tiesc,d

Dist

rict h

ospi

tals

(n =

3)Ru

ral h

ealth

cent

res (

n =

5)Pe

ri-ur

ban

heal

th ce

ntre

s (n

= 6)

Qua

lity

of th

e se

rvic

e (p

erce

ived

or r

eal)

Non

ePo

sitiv

e: (i

) CH

Ws c

lose

ly in

volv

ed in

out

reac

h or

gani

zatio

n an

d in

trac

ing

vacc

ine

defa

ulte

rs; a

nd (i

i) fe

wer

pat

ient

s atte

nded

hea

lth c

entre

s dur

ing

lock

dow

n, le

avin

g m

ore

time

for e

ach

patie

nt.

Neg

ativ

e: (i

) hig

h nu

rse

wor

kloa

d du

e to

com

bini

ng v

acci

natio

n se

ssio

ns a

t he

alth

cen

tres a

nd o

utre

ach

post

s with

nig

ht sh

ifts;

(ii) i

ncre

ased

num

ber

of c

hild

ren

to b

e va

ccin

ated

in e

ach

sess

ion;

(iii)

one

hea

lth c

entre

did

no

t fun

ctio

n w

ell i

n th

e pa

st a

s it p

rovi

ded

only

fixe

d se

ssio

ns a

nd h

ad n

o ou

treac

h fo

r sev

eral

yea

rs; a

nd (i

v) 7

3 ch

ildre

n m

issed

the

seco

nd m

easle

s and

ru

bella

vac

cine

dos

e in

201

8

Posit

ive:

“spl

ittin

g up

the

larg

e ca

tchm

ent a

rea

led

to b

ette

r man

agem

ent.

All v

acci

nes a

re n

ow o

ffere

d ev

ery

day,

exce

pt th

e BC

G va

ccin

e.”

Neg

ativ

e: (i

) “so

met

imes

the

EPI n

urse

has

a n

ight

sh

ift th

e da

y be

fore

the

sess

ion.

Som

etim

es sh

e ca

nnot

atte

nd th

e se

ssio

n”; (

ii) th

e po

pula

tion

is in

crea

sing

at 1

0–15

% p

er a

nnum

but

serv

ices

ca

nnot

kee

p up

; and

(iii)

exp

erie

nced

mot

hers

saw

a

drop

in se

rvic

e qu

ality

due

to in

crea

sed

nurs

e w

orkl

oad

as m

ore

prog

ram

mes

wer

e de

cent

raliz

ed

to h

ealth

cen

tres a

nd h

ealth

pos

ts (e

.g. m

alar

ia,

tube

rcul

osis

and

HIV

serv

ices

and

fam

ily p

lann

ing)

Conv

enie

nt ti

me

(incl

udin

g w

aitin

g tim

e),

plac

e an

d cu

ltura

l con

text

Neg

ativ

e: (i

) miss

ed o

ppor

tuni

ties t

o va

ccin

ate

beca

use

vacc

inat

ion

days

wer

e di

ffere

nt in

di

ffere

nt h

ealth

cen

tres;

and

(ii) C

OVI

D-1

9 re

stric

tions

resu

lted

in a

lack

of i

ndoo

r wai

ting

room

s, m

akin

g it

hard

for c

areg

iver

s and

chi

ldre

n

Posit

ive:

(i) p

rovi

ding

nut

ritio

n se

rvic

es a

nd fa

mily

pla

nnin

g in

add

ition

to

vacc

inat

ion

was

rece

ived

pos

itive

ly; a

nd (i

i) ha

ving

vac

cina

tion

sess

ions

on

mar

ket d

ays e

ncou

rage

s mot

hers

to a

ttend

. N

eutra

l: va

ccin

atio

n is

the

mot

her’s

resp

onsib

ility

and

she

pref

ers t

o co

me

to

the

heal

th c

entre

whe

n th

ere

is a

mar

ket n

earb

y. N

egat

ive:

pro

blem

with

pow

er b

acku

p at

a h

ealth

cen

tre

Posit

ive:

pro

vidi

ng n

utrit

ion

serv

ices

in a

dditi

on to

va

ccin

atio

n.

Neu

tral:

the

day

of th

e w

eek

is le

ss im

port

ant t

han

whe

ther

it is

rain

ing.

N

egat

ive:

(i) w

ith 4

0–50

peo

ple

per s

essio

n, w

aitin

g tim

es c

an b

e up

to 5

hou

rs; (

ii) 6

0–75

or e

ven

100

child

ren

per s

essio

n; a

nd (i

ii) n

urse

wan

ts to

giv

e BC

G va

ccin

e an

d m

easle

s and

rube

lla v

acci

ne o

n th

e sa

me

day

but B

CG v

acci

nes t

ake

time

as th

ey re

quire

a

new

file

and

car

d to

be

mad

e ea

ch ti

me

Des

ign

of v

acci

natio

n pr

ogra

mm

e, v

acci

natio

n sc

hedu

le a

nd d

ata

man

agem

ent a

t hea

lth

cent

res

Posit

ive:

the

trans

ition

to a

dig

ital d

ata

man

agem

ent s

yste

m w

ill im

prov

e th

e fu

nctio

ning

of v

acci

natio

n se

ssio

ns

Neg

ativ

e: (i

) “de

faul

ter t

raci

ng d

idn’

t wor

k w

ell [

due

to p

aper

-bas

ed d

ata

syst

em a

nd h

igh

wor

kloa

d] a

nd p

eopl

e ar

e lo

st to

follo

w-u

p w

hen

they

go

to

the

neig

hbou

ring

dist

rict”

; and

(ii)

data

man

agem

ent s

yste

m d

oes n

ot sh

ow

whe

n pe

ople

are

dro

ppin

g ou

t

Posit

ive:

“Com

pute

rs w

ill b

e in

stal

led

soon

.” N

egat

ive:

(i) i

dent

ifyin

g dr

op-o

uts u

sing

pape

r file

s is

labo

ur-in

tens

ive

and

requ

ires t

he h

elp

of C

HW

s; (ii

) “dr

op-o

uts a

re c

heck

ed a

t the

end

of t

he m

onth

, re

ason

s for

dro

ppin

g ou

t are

exp

lore

d. T

hey

are

usua

lly li

ving

con

ditio

ns, o

r whe

n pe

ople

mov

e to

ano

ther

are

a”; (

iii) c

alcu

latin

g va

ccin

e co

vera

ge

is di

fficu

lt be

caus

e of

the

chan

ging

pop

ulat

ion

in

the

catc

hmen

t are

a; (i

v) a

t the

age

of 9

mon

ths,

child

ren

need

to g

et th

e fir

st m

easle

s and

rube

lla

vacc

ine

dose

at t

heir

own

heal

th c

entre

to re

ceiv

e a

mos

quito

net

; and

(v) “

no fr

ee c

hoic

e of

hea

lth

cent

re fo

r mea

sles a

nd ru

bella

”

BCG:

bac

illus

Cal

met

te–G

uérin

; CHW

: com

mun

ity h

ealth

wor

ker;

COVI

D-1

9: c

oron

aviru

s dise

ase

2019

; EPI

: Exp

ande

d Pr

ogra

mm

e on

Imm

uniza

tion;

HIV

: hum

an im

mun

odefi

cien

cy v

irus;

HPV:

hum

an p

apill

omav

irus;

SARS

-CoV

-2: s

ever

e ac

ute

resp

irato

ry sy

ndro

me

coro

navi

rus 2

.a F

acto

rs w

ere

cate

goriz

ed u

sing

the

3Cs f

ram

ewor

k as

rela

ted

to c

onfid

ence

, com

plac

ency

or c

onve

nien

ce.8

b Com

men

ts w

ere

clas

sified

as p

ositi

ve, n

eutra

l or n

egat

ive

with

rega

rd to

thei

r im

plic

atio

ns fo

r vac

cine

upt

ake.

c Vac

cina

tors

and

Exp

ande

d Pr

ogra

mm

e on

Imm

uniza

tion

staff

wer

e in

terv

iew

ed.

d Det

ails

of w

hich

inte

rvie

wee

s mad

e ea

ch c

omm

ent a

re a

vaila

ble

from

supp

lem

ent 3

in th

e da

ta re

posit

ory.32

(. . .continued)

Bull World Health Organ 2021;99:783–794D| doi: http://dx.doi.org/10.2471/BLT.20.285258794D


Fig. 2. Causal loop diagrams of factors affecting vaccine hesitancy, by factor category, Rwanda, 2018–2020


system

Disease incidence

–

+

Protected population


+

+

++

+

+

Vaccination

Confidence Convenience



Vaccination–


Complacency

–

+

++

–





R Complacency

B Complacency

R Confidence

BConfidence

Vaccination



Individual health

R Convenience

B Convenience



Protected population

+

+

++

+

+

+

Notes: Factors affecting vaccine hesitancy were categorized using the 3Cs framework as related to confidence, complacency or convenience.8 The R loops are reinforcing feedback loops that cause change in the same direction and the B loops are balancing loops that cause change in the opposite direction.For confidence, reinforcing factors represented by the R loop include: (i) respectful relationships with health centre staff and community health workers engenders trust in vaccine services; (ii) mothers overcome fear of being late for immunization when they know the nurse and feel welcome; (iii) multiple contacts between the caregiver and nurse increases trust; and (iv) an entry in the mother-and-child booklet indicating immunization has been completed is encouraging for both caregivers and their families. Balancing factors represented by the B loop include: (i) long waiting times; (ii) short contact times between nurse and caregiver, which give the nurse little time to explain vaccination (one reason was numerous administrative tasks and demands from other vaccination programmes); and (iii) suspension of educational sessions before vaccinations during the coronavirus disease 2019 pandemic.For complacency, reinforcing factors represented by the R loop include: (i) a well-protected population experiences fewer cases of disease, which increases the perceived benefit of vaccination and community engagement. Balancing factors represented by the B loop include: (i) a decline in cases of disease lowers both awareness of the threat to young children and the perceived importance of vaccination; and (ii) caregivers worry less about their children’s health as they grow up, which increases complacency and can lead some to deprioritize their vaccination appointments.For convenience: reinforcing factors represented by the R loop include: (i) families that are healthy, literate and financially stable are more likely to understand their appointment schedule and can afford to travel to health centres to vaccinate their children. Balancing factors represented by the B loop include: (i) the risk of a disease outbreak is increased in poorly protected populations (which can be remedied by immunization campaigns and enhanced vaccination services, including outreach).

insights into vaccine hesitancy from systems thinking, rwanda

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