A Rapid Qualitative Assessment of Oral Cholera Vaccine Anticipated Acceptability in a Context of Resistance towards Cholera Intervention in Nampula, Mozambique

"The anthropological approach enables the assessment of current perceptions and political dynamics, which orients the implementation of public health initiatives and enables the elaboration of collaborative community-based communication strategies and health interventions."

Conducted in a community in Nampula, Mozambique, where resistance to cholera interventions has been reported, this rapid anthropological assessment sought to evaluate potential barriers and levers for oral cholera vaccine (OCV) acceptability, and to establish appropriate vaccination campaign and social mobilisation strategies.

The political context in Mozambique has changed over time, which may influence social determinants for the acceptability of health interventions. In Nampula, episodes of violence occurred among the population during protests against water source-chlorination response teams. In 2009, 16 people were killed after having been accused of spreading cholera instead of preventing it (purifying the wells).

Neighbourhoods were selected for the November 2016 OCV campaign from epidemiological records, based on higher cholera incidence between 2011 and 2016. In preparation for the campaign, as part of this study, questionnaires, in-depth interviews (IDIs), and focus group discussions (FGDs), as well as observations, were conducted. The 143 participants included central and district level government informants (national immunisation programme, logistics officers, public health directors, and others), community leaders and representatives, and community members.

Among the study participants, 95% reported knowledge about what cholera is. When asked about the principal causes of cholera, 66% reported "dirtiness" (dirty water: 57% and dirty food: 39%). IDIs provided information on alternative perceptions of what causes cholera. Some participants contrasted natural causes (lack of hygiene, transmission via oral-faecal routes) and unnatural causes and identified cholera as a "non-regular disease", which was correlated with mistrust towards the government, whom respondents perceived to be responsible for cholera spread, motivated by political malice or negligence. To support this argument, respondents identified the uneven geographical cholera distribution, inducing a perception of being "forgotten": "why aren't you coming to remove the trash that's killing us?" (municipality representative). This comment suggests a theme that emerged from the study: "In Nampula, potential vaccine acceptance or refusal arises not only from political divisions; rather, it is a consequence of despair in the face of perceived social inequality, insecurity, and government inaction. Social inequality may trigger attitudes of OCV hesitancy and lack of trust in those perceived as 'the rich and the powerful', the 'select few' who are thought to reap the benefits of the development of Nampula city."

Respondents also reported vaccine hesitancy related to experiences of problems during school-based vaccine introduction, rumours related to vaccine safety, and negative experiences following routine childhood immunisation.

Respondents described a lack of community engagement in cholera interventions, as community leaders were not asked for permission or appropriately informed about planned interventions. Along those lines, some discussed difficulties with school-based polio vaccine introduction: "Whenever the vaccination came, there was panic, all the students were shouting, the people were running away...they could even go out through the windows" (primary school teacher). This behaviour was a consequence of parents and children "not being informed" (head community leader) - or being insufficiently informed - about the intervention.

Despite major suspicions associated with the OCV campaign, respondents' perceived vulnerability to cholera and its perceived severity seem to override potential anticipated OCV vaccine hesitancy: The willingness to be vaccinated was very high (95%). Most participants described vaccines in general (i.e., not specifically OCV) in positive terms with regard to safety and efficacy. In addition, a majority of respondents reported having personally experienced or had a family member or friend who had experienced cholera.

Nampula public health officials indicated that they had led trust-building initiatives to overcome the issues associated with well chlorination. For example, the name of the substance used to purify the water was changed from "cloro", which was perceived as resembling "cólera", to "certeza". They also performed house-to-house information campaigns, and social mobilisers demonstrated the safety of purified water by drinking it themselves in front of community members. Similarly, new medication introduction hesitancy was mitigated thanks to the involvement of primary school teachers, who took the tablets themselves in front of their pupils.

In Nampula, recommended communication strategies included: information provided by social mobilisers using a door-to-door strategy; messages delivered via a megaphone in churches, schools, mosques, markets, and in the streets; and campaign announcements on television and radio. Community leaders' involvement (via interpersonal communication and collective gatherings) was described as critical for mitigating potential conflicts. Bypassing the authority of community representatives was reported to increase the risk of retaliatory acts.

Respondents indicated that key messages should be conveyed in simple terms, using the local language, and should include all necessary information related to: campaign logistics; the safety of a vaccine delivered by the oral route; details on past OCV implementation in Mozambique and other countries; and individual ability to refuse the vaccine.

In conclusion, these findings illustrate the importance of understanding the local context in detail prior to implementing immunisation campaigns. In this context, some recommendations include: a strong involvement of community leaders, which is important for successful social mobilisation; the inclusion of representatives of different political parties in social mobilisation efforts, before and during campaigns; and promotion by public health officials of other planned interventions (such as water, sanitation, and hygiene improvements) to mitigate the lack of trust associated with perceived institutional negligence. There is a role for locally based trust-building initiatives to promote community engagement.