Insights into vaccine hesitancy from systems thinking, Rwanda.

Area of Science:

• Public Health
• Behavioral Science
• Health Systems Research

Background:

• Vaccine hesitancy contributes to underimmunization and disease outbreaks, as seen in a recent measles outbreak in Rwanda.
• Understanding the complex behavioral factors influencing vaccination decisions at the community level is crucial for effective public health interventions.

Purpose of the Study:

• To investigate the drivers of vaccine hesitancy and underimmunization in Rwandan communities.
• To develop a conceptual, community-level model of behavioral factors influencing vaccine uptake.
• To identify strategies for increasing immunization rates and preventing future outbreaks.

Main Methods:

• Employed systems thinking, human-centered design, and behavioral frameworks to explore immunization systems in two Rwandan communities.
• Collected data through discussions with 11 vaccination service providers and interviews with 161 caregivers between 2018 and 2020.
• Utilized the 3Cs framework (confidence, complacency, convenience) to categorize factors influencing vaccine hesitancy.

Main Results:

• High trust in vaccines and providers, the role of community health workers, and strong community ties positively influenced vaccine uptake.
• Factors increasing hesitancy, such as service accessibility and follow-up, varied between providers and caregivers, and across settings.
• A conceptual model was developed to explain the measles outbreak drivers and guide interventions.

Conclusions:

• Behavioral frameworks and systems thinking revealed intricate mechanisms linking immunization services and caregiver behavior in Rwanda.
• Confidence-building social structures and context-specific challenges significantly impact vaccine uptake.
• The study provides insights for designing targeted interventions to improve immunization coverage and public health outcomes.