Abstract
Background
Several months after COVID-19 vaccines became available in Liberia, only a small percentage of the population had received their first dose. Whereas prior data have demonstrated that an individual’s family can have a strong normative influence on health behavior, few studies have explored how behavioral intent about vaccination among household members affects individual vaccination acceptance. Such data are particularly lacking in rural, resource-limited settings like Liberia, where vaccination update remains low.
Research aim
We respond to this gap in knowledge by analyzing data from a household survey of women in rural Liberia with the goal of understanding how household COVID-19 beliefs and vaccine behavioral intent correlated with individual household members’ beliefs and vaccine behavioral intent. Our overarching aim was to identify targets to increase vaccination uptake in rural Liberia.
Methods
We analyzed data from a population-representative, household-based stratified cluster-sample survey in Grand Bassa County, Liberia, conducted from March to April 2021. All women aged 15-49 in selected households were invited to complete a questionnaire, which included a COVID-19 module on protective health behaviors and vaccine acceptance. Because vaccines were not available in this setting at the time of the survey, the question that asked about vaccine acceptance measured behavioral intent rather than current behavioral practices. We defined each household as being concordantly vaccine hesitant, concordantly vaccine accepting, and discordant (some members accepting and some members not accepting of vaccination). We fitted multivariable logistic regression models to identify correlates of concordant acceptance. The model was adjusted for potential confounders, including individual age, wealth (constructed as a household-level wealth index using principal components analysis), education, distance to nearest health facility, and National Community Health Assistant Program (NCHAP) implementation status.
Key results
A total of 2,620 women in 2,201 households completed the survey. Forty-two percent of households had discordant views on the vaccine, versus 33% of households concordantly accepting, and 25% concordantly hesitant (n = 352). There were no significant differences in demographic characteristics between households that had discordant, concordantly accepting, and concordantly hesitant vaccine beliefs. In adjusted models, having a household member who is accepting of the COVID-19 vaccine was associated with an 18.1 percentage point greater likelihood of being accepting of a COVID-19 vaccine (95% CI 7.3-28.9%, p=0.001). The other correlate of vaccine acceptance at the individual level included living 10 to less than 20 kilometers from the nearest health facility (95% CI 0.2-13.8%, p=0.043).
Conclusions and implications
Only approximately one in three households in a rural community in Liberia were fully COVID-19 vaccine accepting. The strongest predictor of whether someone was accepting of the COVID-19 vaccine was whether someone else in their household was also vaccine accepting, and increased the proportion of acceptance by nearly 20 percent. Social norms around vaccine acceptance within households appear to be a major determinant of individual acceptance. Interventions that target hesitant households may have an outsized effect on vaccine acceptance rates in this setting.