COVID-19 Vaccination in Lower-Middle Income Countries: National Stakeholder Views on Challenges, Barriers, and Potential Solutions

"The study raises awareness about the uniqueness of COVID-19 vaccination for further consideration by decision makers in emerging economies as they prepare to scale up vaccination."

COVID-19 vaccine acceptance and hesitancy remain a significant issue, with studies reporting mixed results on vaccine hesitancy in low- and middle-income countries (LMICs) compared to high-income countries (HICs). LMICs, where rollout has been slower, will likely encounter additional challenges compared to HICs. This study explores barriers that may potentially arise during the COVID-19 vaccine rollout in Bangladesh and Ghana, and how to overcome these barriers.

The researchers conducted 16 semi-structured interviews with national-level stakeholders from Ghana and Bangladesh, two LMICs with similar World Bank classification. Stakeholders included policymakers and immunisation programme experts. Data were analysed using a framework analysis technique.

Demand-side barriers, illustrated by quotations in the text and accompanied by suggested strategies for addressing them, include:

• Vaccine safety concerns - Stakeholders explained how beliefs of vaccine inefficacy and adverse events following immunisation (AEFIs) increase vaccine hesitancy in the public. For example, concerns about rushed vaccine trials and approval threatened confidence in COVID-19 vaccines in India. Stakeholders from both countries suggested offering public education and leverging community influencers to create awareness and contradict rumours or incorrect information about the virus and vaccination. Electronic and print media, and use of community and mass media, are viable platforms/approaches. They also reported that national vaccine approval by government-accredited institutions could allay the public's doubts and fear about vaccines.
• Vaccination service-related barriers - Interviewees identified vaccination fatigue (related to multiple doses and potential future boosters) and the direct and indirect cost of vaccination to consumers as vaccine uptake barriers. Participants did not discuss strategies to address these particular barriers.
• Social/religious- and culture-related barriers - Stakeholders said complacency and group resistance are associated with vaccine rejection. For instance, less-affected social groups like youth do not feel as threatened by COVID-19, which might infect them but leave them asymptomatic (though able to spread the disease). Stakeholders in both countries said that some population groups believe COVID-19 is a disease of the wealthy and specific religious groups. A participant in Bangladesh reported social group resistance among some tribal and religious groups. Stakeholders proposed strategies similar to those they described to address vaccine safety concerns - e.g., "we try to use opinion leaders, civil society organisations. We worked together with chiefs, queen mothers, church leaders and mosque leaders..."

Stakeholders also anticipate a number of supply-side barriers, in the following categories: vaccine production and cost-related barriers; vaccine distribution and storage-related barriers; vaccine delivery and administration-related barriers (e.g., geographically inaccessible communities or migrating persons); and vaccination programme monitoring and evaluation barriers (e.g., poor telecommunication and internet connectivity). Examples of strategies they proposed to address these supply-side barriers include: using existing vaccine delivery and administration systems set up for the Expanded Programme on Immunisation (EPI), training more health providers and recruiting volunteers to increase vaccination speed.

The researchers reflect on some of the stakeholders' proposed strategies for both demand- and supply-side barriers. For example, public education campaigns and health provider recommendations "have effectively addressed vaccine hesitancy in previous vaccination programmes, but the approach may be less effective for COVID-19, particularly in African countries, for at least two reasons: (a) the public distrusts the centralised COVID-19 response due to the lack of urgency and strictness that characterised governments and public health experts' response at the initial stages of the pandemic..., and (b) non-involvement of local authorities in the design and campaign for preventive measures." The researchers suggest that use of community influencers, which the stakeholders discussed, may be a more promising strategy to increase trust in COVID-19 vaccines. "LMICs could leverage communities' trust in influencers such as chiefs, pastors, and Imams to debunk conspiracies, allay fears and increase COVID-19 vaccine uptake."

In conclusion: "Governments should develop their immunisation systems beyond EPI systems to accommodate the pressure of high demand, including by expanding procurement mechanisms and designing localised community influencer-led education campaigns to allay people's fears and increase COVID-19 vaccine acceptance....Future studies should consider the perspectives of service providers and vaccine receivers on barriers to COVID-19 vaccinations and the strategies to overcome them."