The resulting factors that influenced acceptance or non-acceptance of RI and HPV vaccines are summarized in Figure 2. Each bubble represents the identified vaccine hesitancy drivers in reference to RI (left), to HPV vaccination (right), or both (middle). The figure summarises results from both KII and FGD.
Factors Driving Vaccine Hesitancy toward Routine Immunisation
Competing or Poorly Scheduled Healthcare Services: Participants reported that based on their experiences, “outreach clinics are opened most of the time around 9:00am. Sometimes outreach clinics are missed by caregivers due to other services scheduled at the same time, such as family planning and ante-natal care services” (HCW 2, Salima District). Outreach clinics are usually makeshift medical services stepped down to reach disadvantaged communities or hard-to-reach terrains, to provide essential healthcare services, especially immunisation services. Participants alluded to missed appointments resulting in incomplete immunisation when all the immunisation services were not centralized in one spot or operated on different schedules.
Individual and Group Influence
Lack of Confidence: The study participants acknowledged the presence of RI and other types of immunisation services that are being provided in Malawi. However, most participants reported that despite the number of almost five to six healthcare workers providing some of these services at the facility, which was adequate for the setting, the number of adolescent girls and under-fives receiving vaccinations remained low in some districts. A FGD 001 participant alluded to confidence issues: “Many people do not trust immunisation because of stories they hear” (EPI Manager, Zomba District).
Attitude toward Vaccination versus Behaviour: Study participants acknowledged that vaccination is vital to caregivers for protecting their children against vaccine-preventable diseases and agreed that vaccination is a vital topic within their household. However, immunisation was not considered a top priority: “immunisation is very important but there are other equally important things to the family” (Caregiver 2 - Dowa District; FGD002). Further probing indicated the dominance of husbands in household vaccination decision-making as a factor that prevented turning intentions into behaviour. “Well, even though we know the importance of immunisation, our husbands must still agree before we can carry our children to hospital” (Caregiver 1; FGD, Dowa District). “On major market days, attendance is poor because mothers take husbands’ farm produce to market, so they miss childhood immunisation” (HCW 1; FGD, Dowa District).
Inadequate Resources Decrease Motivation for Vaccination Uptake
Most participants reported a lack of resources and medical equipment at village clinics. These necessitated caregivers to sacrifice their personal items for immunisation activities, hence reducing their motivation and willingness to want to continue immunisation. “We use our own resources (e.g., transportation, sanitary items, furniture, etc.) whenever we want to do vaccination activities at the village” (HCW 2, Lilongwe).
Low Literacy Level of Caregivers: The participants also revealed that their caregivers’ literacy levels are very low in the communities. This makes the effective health promotion of issues surrounding the importance of vaccination difficult, especially for those without any formal education: “Sometimes some people distribute pamphlets on immunisation, but many of us cannot read” (Caregiver 1, Zomba district).
Distance and Logistics in Accessing Health Centers: The majority of participants described long distances of travel to the clinics, impacting uptake of vaccination: “Lack of easy access to health centers results in lots of missed immunisation schedules” (Caregivers 1, Zomba District). These sentiments were echoed among all caregivers.
Disconnect between Healthcare System and Community Gatekeepers/Leaders
Most participants revealed that essential stakeholders (e.g., community leaders, religious leaders, etc.) were usually not consulted by the Expanded Program on Immunisation (EPI) and Healthcare System managers. “The EPI does not care about our opinion” (CL, Dowa District). This affected not only attitude, but also the turnout for both RI and adolescent girls for the HPV vaccine.
Factors Driving Hesitancy toward the Human Papillomavirus Vaccine
Lack of Confidence in Safety and Effectiveness of HPV Vaccine
There were some levels of awareness and even campaigns; however, the communities are not always confident that the HPV vaccine is safe and effective. In many districts, “parents generally, especially fathers, are reluctant to let their eligible daughters receive the HPV vaccine” (HCW 1-2, Lilongwe, Caregivers 1-2, Zomba). “We have heard about the HPV vaccine, but we are not sure about it” (Caregiver 1; RL, Dowa/Zomba/Lilongwe).
Attitude Toward Vaccination versus Behaviour
More than half of the study participants in all four districts acknowledged that there was knowledge of the HPV vaccine; however, this knowledge has not translated into behaviour. The negative behaviour might be connected to the perception of existing traditional beliefs and cultural practices, which have not changed about vaccination in general and specifically about a vaccine that targets young girls (HPV vaccine). “We have not been convinced why the vaccine targets our girls specifically” (Caregivers 2, Lilongwe/Dowa/Lilongwe/Zomba). Therefore, high intentions to vaccinate due to knowledge about the HPV vaccine did not affect uptake behaviour.
The caregivers do not believe cervical cancer was prevalent because there are almost no cervical cancer screening opportunities outside the main city centers. “There is little data to support arguments about high HPV prevalence in our area” (CSO, Salima District). This attitude generated low risk perception of HPV, hence complacent behaviour.
Lack of Awareness of Vaccination Schedule
Participants expressed a lack of awareness of the vaccination schedule (dates/timing) as a reason why caregivers missed both routine and HPV vaccinations.
Individual and Group Influences
Misconceptions, Rumours, and Conspiracy Theories: The participants reported a misconception that once their daughters get vaccinated against HPV, they become infertile. Other caregivers queried why HPV vaccines target only girls: “Ignorance among community members because of rumours on the HPV vaccine drives vaccine hesitancy…such as the belief that the HPV vaccine will reduce the libido of girls when they become sexually active and make them become reproductively infertile” (EPI Logistician, Dowa/Zomba).
Participants discussed that there were no widespread traditional or cultural beliefs among Malawian communities that specifically hindered vaccine acceptance. However, there were some specific misconceptions about the vaccine, especially from the Zion and Apostolic faith sects. These groups denied some aspects of modern medicine, including vaccinations, and amplified conspiracy theories surrounding the HPV vaccine, such as that it promotes immoral behaviour and leads to infertility among the recipients. “The HPV vaccine promotes promiscuity and exposes young girls to sex and abortion” (RL, Salima/Zomba).