Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya

RESEARCH Open Access

Community perceptions of malaria and vaccinesin the South Coast and Busia regions of KenyaDavid I Ojakaa1*, Peter Ofware1†, Yvonne W Machira2†, Emmanuel Yamo1†, Yvette Collymore3†,Antoinette Ba-Nguz4†, Preeti Vansadia4† and Allison Bingham5†

Abstract

Background: Malaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya.Within the context of planning for a vaccine to be used alongside existing malaria control methods, this studyexplores sociocultural and health communications issues among individuals who are responsible for or influencedecisions on childhood vaccination at the community level.

Methods: This qualitative study was conducted in two malaria-endemic regions of Kenya–South Coast and Busia.Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depthinterviews, and 18 exit interviews were conducted.

Results: Participants understand that malaria is a serious problem that no single tool can defeat. Communitieswould welcome a malaria vaccine, although they would have questions and concerns about the intervention.While support for local child immunization programs exists, limited understanding about vaccines and what theydo is evident among younger and older people, particularly men. Even as health care providers are frustratedwhen parents do not have their children vaccinated, some parents have concerns about access to and the qualityof vaccination services. Some women, including older mothers and those less economically privileged, seethemselves as the focus of health workers’ negative comments associated with either their parenting choices ortheir children’s appearance. In general, parents and caregivers weigh several factors–such as personal opportunitycosts, resource constraints, and perceived benefits–when deciding whether or not to have their childrenvaccinated, and the decision often is influenced by a network of people, including community leaders and healthworkers.

Conclusions: The study raises issues that should inform a communications strategy and guide policy decisionswithin Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education onchild welfare and immunization focuses on women, the communications strategy should equally target men andwomen in ways that are appropriate for each gender. It should involve influential community members andprovide needed information and reassurances about immunization. Efforts also should be made to addressconcerns about the quality of immunization services–including health workers’ interpersonal communication skills.

BackgroundDespite progress in fighting malaria worldwide, theparasitic disease kills close to 800,000 people annually[1]. In Kenya, an estimated 27 million people (about 70percent of the population) are at risk of infection, androughly 34,000 young children die of malaria-related

causes annually [2]. Current interventions in Kenyainclude the use of long-lasting insecticide-treated nets,indoor residual spraying with insecticides, intermittentpreventive therapy with sulphadoxine-pyrimethamine forexpectant mothers, and artemisinin-based combinationtherapies for malaria case management [2].Recent advances in malaria vaccine development have

heightened the possibility that, if proven effective, a newanti-malaria tool could be deployed for use alongsideexisting interventions [3]. A vaccine candidate targetingthe most life-threatening malaria parasite, Plasmodium

* Correspondence: [email protected]† Contributed equally1African Medical and Research Foundation, Wilson Airport, Langata Road, POBox 30125, Nairobi, KenyaFull list of author information is available at the end of the article

Ojakaa et al. Malaria Journal 2011, 10:147http://www.malariajournal.com/content/10/1/147

© 2011 Ojakaa et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

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falciparum, is moving through a Phase 3 efficacy trial inKenya and six other African countries–Burkina Faso,Gabon, Ghana, Malawi, Mozambique, and Tanzania [3].Data from previous studies indicate that this vaccinecandidate–GlaxoSmithKline Biologicals’ RTS, S–may cutepisodes of clinical malaria in young children by abouthalf [4]. If the efficacy trial confirms earlier findings, theWorld Health Organization (WHO) has indicated that apolicy recommendation for RTS, S is possible as early as2015, paving the way for implementation in countriesthrough their expanded programs on immunization.Final results from the trial are expected in late 2014.But experience has shown that licensing a new health

intervention hardly guarantees its timely use. In develop-ing countries, it has taken up to two decades for new vac-cines to become available to communities after they arelicensed [5]. Similarly, while the malaria vaccine commu-nity’s 2015 mark for a first-generation product [6] maybe within reach, the actual introduction and use of a newvaccine could be held up for years because of a variety offactors. For example, the absence of critical data couldslow down the process that policymakers must undertaketo determine whether or not to introduce a particularintervention into their health systems [7]. In addition,misinformation within communities or poorly handledinformation by decision-makers could result in an out-right lack of support for an intervention by local commu-nities even after it has been introduced [8].The formative study described in this paper is meant

to address these communications needs. Informationgathered is meant to add to the range of well-timeddata required by policymakers to reach a decision onwhether or not to add a malaria vaccine to their existingmethods [7]. The information is also meant to informthe design of a communications strategy, including waysto engage communities well before a malaria vaccinebecomes available. This paper presents the results of thestudy in Kenya within the context of informed decision-making related to future malaria vaccines and with aneye to the elements that should form the basis of a com-munications strategy, including those factors that poten-tially motivate or represent constraints to vaccination.The impetus for this study came from several sources.

The wider malaria vaccine community called for thisinformation to help African decision-makers betterunderstand how and whether they should introduce amalaria vaccine for use with other malaria interventions[6]. Responding to this call, in 2006, the PATH MalariaVaccine Initiative (MVI), WHO, and national immuniza-tion and malaria control programs in several Africancountries outlined the data required to assess the needfor such a vaccine [7]. In addition, WHO’s frameworkfor new vaccine introduction calls this type of research akey step toward vaccine introduction, as it provides a

solid evidence base for, among other things, designingan informed communications strategy [9]. Other expertshave also concluded that it is essential to understandthe relevant sociocultural context for a new health inter-vention, such as a vaccine, to be successful [10].The relevant literature on immunization programs and

services in sub-Saharan Africa highlights the importantrole of communications. Some research shows thatwhile communities are generally knowledgeable aboutvaccine-preventable diseases, mothers may lack key vac-cination schedule information, such as how many vacci-nations their children should receive or by what agethey should have completed the course of vaccines [11].A communications strategy could also take into accountany beliefs about disease severity that may influencewhether a child is vaccinated.Other research has pointed to the importance of com-

munications on issues around access to services, such asthe distance that some families must travel for vaccina-tion at primary health care facilities [12] and interac-tions between vaccination providers and users. Adistrustful climate between communities and immuniza-tion programs can contribute to growing pools of non-immunized and partially immunized children [13-15].Recent research also points to the key role that trustedsources or opinion leaders can play in fostering accep-tance for vaccination [16]. In this regard, health careproviders are themselves seen as important influencersof parents and other caregivers [15].With all this in mind, the African Medical and

Research Foundation (AMREF) in Kenya worked withMVI to explore sociocultural and health communica-tions issues among individuals at the community level–both those responsible for decisions about vaccine useand those likely to influence such decisions. The study’sobjectives were also closely tied to the need to identifyand describe target audiences and to highlight the rele-vant beliefs, values, attitudes, knowledge, and behaviorsof these audiences prior to the introduction of an inter-vention [17]. The study therefore had the following spe-cific objectives:

• To determine the perceptions, beliefs, practices,and information gaps related to malaria and vaccinesamong caregivers, service providers, and others atthe community level.• To determine household decision-making andtreatment-seeking patterns related to malaria andvaccination.• To identify key audiences and communications andinformation channels at the community level.

Given these objectives, it is nevertheless important toemphasize that this study should be seen as formative in


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nature. It is meant to inform other studies on percep-tions of vaccination in relation to possible malaria vac-cine introduction.

MethodsSite selectionThe formative study was conducted in two regions ofKenya. Sites were selected based on a variety of factors,with the primary and secondary factors being malariaendemicity and local community and stakeholder supportfor conducting the study. High endemicity was sought toobtain data rich in experiences with malaria. Thereafter,variations in data were sought based on criteria such asability to sample rural and urban populations, diversity inethnic groups, and variation in religion.The two study regions selected were the larger Busia

region in Western Province and South Coast in CoastProvince. Busia, situated in the Uganda-Kenya borderregion near Lake Victoria, is considered a highly endemicmalaria region with year-round transmission [18]. Withinthe Busia region, study participants resided in the follow-ing areas: Busia Township, Bunyala, Samia, Butula, andNambale. This predominantly Christian region is primar-ily home to the Luhya tribe. Dominant languages spokenby study participants were Luhya and Kiswahili.The South Coast region is considered highly endemic

with perennial malaria transmission; however, morerecent data indicate that malaria is declining in theregion [19]. The rural and urban areas sampled includedKwale, Kinango, Msambweni, and Mombasa. The SouthCoast region has greater Arab influence, is of Swahiliculture, and has a higher proportion of Muslims thanother parts of the country. Languages spoken by studyparticipants were Digo, a dialect of the Mijikenda lan-guage, and Kiswahili.

Participant selection and data collectionParticipant selection was largely purposive and criterionbased. Criteria were based on a literature review and anecological conceptual framework, commonly used inhealth planning formative studies [20]. This frameworkwas successfully adapted for use by PATH in other newchild vaccine planning studies [21]. The frameworkrecognizes levels or categories of people who influencewhether a child is immunized. These levels constituteimportant target audiences for developing a health com-munications strategy aimed at engaging communities innew vaccine introduction activities. They include:

1. The individual level: Parents and other caregiversof children.2. The interpersonal level: Secondary influencerssuch as teachers, health workers, and the media andother communicators.

3. The community level: Community leaders, localadministrators, and local government officials.4. The institutional level: Health care personnel andadministrators.

Seven research assistants (four in the Coast region andthree in the Busia region) were recruited for data collec-tion. All seven (three men and four women) had degreesin related social sciences and had prior experience withqualitative interviewing. They were native speakers of therelevant local languages and speakers of the secondnational language, Kiswahili. Training of the researchassistants and pre-testing of tools were carried out inOctober 2009. The training, which took place in thecoastal city of Mombasa, covered an introduction toMVI’s Community Perceptions Study and a re-orientationon such qualitative research approaches as data collection,obtaining informed consent, and analysis. Study tools werealso reviewed, translated, and back-translated. Thereafter,pilot-testing was completed in the Coast region, and datacollection activities began in November 2009. All activitieswere monitored by senior research staff.A total of 20 focus group discussions (FGDs) were

held, with 234 participants; 22 key informant interviewswere conducted; and 18 exit interviews were completedin maternal and child health clinics (Table 1). FGDswere held with similarly situated respondents (e.g.,mothers between 18 and 24 years of age) in an effort tosolicit more candid responses. In addition, data werecollected on vaccine delivery, immunizations, andadministrative services from the health facilities visited.FGDs and in-depth interviews were both noted and

recorded, then later transcribed and translated from thelocal languages–Luhya, Digo, and Kiswahili–to English.Researchers carried out thematic content analysis using acodebook process on the translated English transcripts. Toensure maximum data validity and verification of findingsat different levels, two iterations of analysis were conducted.Researchers first reviewed the transcripts for key themesusing an iterative discursive process and developed a mastercodebook. At the second level, the researchers worked withan analyst versed in Atlas. ti software to code the data elec-tronically and then generate reports to further explore the-matic relationships and variations in the data by site, age,category of focus group participants, and type of interview.

Ethics approvalThe study was reviewed in Kenya by the AMREF Ethicsand Scientific Review Committee and in the UnitedStates by the PATH Research Ethics Committee.

ResultsResults are organized in three general thematic areas:perceptions of and experiences with malaria; perceptions


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of and experiences with child immunization; and consid-erations for a future malaria vaccine (Table 2). Since theanalysis included a comparative examination of findingsby region, gender, and study group, observable differ-ences are highlighted where they exist.

Sociodemographic characteristics of study participantsParticipants resided mainly in rural areas, though somelived in the urban slum areas of Mombasa. Among par-ents and community representatives, small-scale farmingand small business were common occupations. Thosewith formal employment included pharmacists, healthcare providers, and government officials. Income varia-tions were notable by age group and region. For partici-pants older than 50, remittances by children were cited

as a main source of income. And while cross-border,small business was common in Busia, income stemmingfrom the tourist industry in the Coast was noted.

Perceptions of and experiences with malariaMalaria is a serious health concernOverall, malaria appeared to be well known to the com-munity. Study participants shared their experiences withthe disease from the perspective of parents who had lostchildren, caregivers for other family members, observersof patients, and patients themselves. Participants in allgroups noted that malaria was a serious health problemthat could lead to the deaths of adults and children,cause weight loss, and contribute to poor school perfor-mance. The consensus across the groups that malaria

Table 1 Sampling framework and final sample size

Busia region South Coast region/Mombasa district Numberofevents

Focus group discussions

Mothers 50+ years old Mothers 50+ years old

Fathers 50+ years old Fathers 50+ years old

Mothers 25-49 years old (2 groups) Mothers 25-49 years old (2 groups)

Fathers 25-49 years old Fathers 25-49 years old

Mothers 18-24 years old Mothers 18-24 years old


Mothers 18-49 years old Mothers 18-49 years old


Community health workers Community health workers 20

Key informant interviews

Woman leader, youth leader, assistant chief, pastor, teacher,shopkeeper, traditional birth attendant, civil society organizationrepresentative, district public health officer, district nutritionist

Woman leader, youth leader, chief, pastor, imam, traditional birthattendant, civil society organization representative, teacher, localpharmacist, district public health officer, district medical officer,district public health nurse

22

Clinic exit interviews

Mothers in an antenatal clinic (3) Mothers in an antenatal clinic (3)

Mothers in a child welfare center (3) Mothers in a child welfare center (3)

Mothers with febrile children (3) Mothers with febrile children (3) 18

Total 60events

Table 2 Themes explored in the study

Theme Thematic areas explored

1. Perceptions and experiences with malaria • Perceptions of women and men around malaria.• Perceived causes of malaria.• Community experiences with malaria control efforts.

2. Perceptions and experiences with childimmunization

• Community experiences with vaccination programs and the health system.• Community perceptions of factors that influence immunization coverage and acceptance of anew vaccine.• Decision-making around child vaccination.

3. Considerations for a future malaria vaccine • Reactions to the prospect of a new vaccine.• Expectations for a new vaccine.• Concerns about a possible new vaccine.• The concept of efficacy.


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had a negative impact on economic and family stabilityis reflected in an older father’s comment:

Malaria has really affected my family, and as we aretalking, I have two children who are suffering frommalaria. I brought them to the hospital and theywere treated for malaria; I went back home withthem and they improved. After a while, they gotmalaria again and I came back to the hospital andthey were treated, but again they got malaria oncemore after getting back home. Now, my earnings areaffected because coming to the hospital is money andit becomes difficult to bring them back to the hospitalsince money is a problem. (Participant, FGD fathers50+, Coast region)

Participants recognized a similar cluster of symptomsof malaria across settings. In addition, fever may some-times be equated with malaria and consequently, otherillnesses that manifest fever as a symptom may also bedescribed as malaria. The most commonly mentionedsymptoms included headaches, body aches, fever, con-vulsions, vomiting, diarrhea, dehydration, loss of appe-tite, weight loss, low blood levels, red eyes, coughing,sneezing, fast breathing, restlessness, and depression.Some participants also referenced temporary madness(during severe episodes of malaria).Who is at risk for malaria?Although everyone was said to be at risk for malaria,focus group discussants generally recognized that groupswho were particularly vulnerable to the disease includedpoor people and children–those between 9 months and5 years of age, those younger than 15 years, and new-borns. The antenatal and postnatal periods were identi-fied as risk periods for the mother.What causes malaria?Most study participants understood that malaria istransmitted by mosquitoes. At the same time, parents inFGDs identified a number of factors as traditionallyaccepted causes of malaria, especially among children.For some, simply overeating or eating certain plantfoods, such as raw mangoes, groundnuts, and youngsugar cane, was reported as associated with gettingmalaria. Many parents also cited cold-water baths andweather-related causes, including exposure to dew andrain and spending the night in cold conditions (as isusually the case during funerals). In the Busia region,participants from the flood-prone district of Bunyalaattributed high malaria incidence to flood waters.The “forces of evil” as a cause of malaria emerged as

an important perception in both regions. Mainly articu-lated in FGDs involving older participants, this percep-tion was also highlighted by community health workers,who have a keen understanding of their communities.

This factor was also more frequently cited in the Coastregion, compared with Busia. In this regard, the nyuni(a bird) was often reported to be a common cause ofmalaria, as were evil spirits, known in the coastal Digolanguage as tsagwa. Going against cultural prohibitions–such as a woman having sexual relations soon afterbirth–was also seen to cause malaria. Professionals suchas teachers, health care providers, and pharmacists inboth South Coast and Busia tended to cite the scientificcauses of the disease (e.g., bites by infectious mosqui-toes), rather than these traditional beliefs.Preventing malaria-like illnessesParents in the two regions appeared to be engaged insimilar practices to prevent malaria in their children.Sleeping under mosquito nets was reported to be one ofthe best malaria control methods. However, parentsnoted that nets may not always be affordable or avail-able and that using them may be inconvenient. Otheranti-malaria measures for parents in both the Busia andCoast regions included keeping the house and surround-ings clean, indoor and outdoor spraying with insecti-cides, the use of mosquito repellent jelly and mosquitocoils, drainage of stagnant water, and the pouring ofparaffin oil on water to kill larvae. They also reportedkeeping doors and windows closed during the eveningsand the indoor burning of cow dung, ubani (incense),and the leaves of the obengele, obwali, or mvumbanitrees to repel mosquitoes.Treating malaria-like illnessesWhile study participants talked about taking sick chil-dren to clinics, the first steps in managing malaria-likeillnesses often appeared to be home based. First-linemalaria care therapies for some involved the purchase ofnon-prescribed painkillers such as Panadol and Calpol.The use of herbs and traditional healers was also com-monly mentioned across groups and settings, with parti-cipants saying that families often took children totraditional healers when home-based treatment was noteffective. Some parents reported that children may bebathed in cold water to bring down temperatures, cov-ered with blankets, or given large quantities of boiledwater to drink. In one FGD in the Coast region, parentsexplained that a mother may have the sick child lie flatand urinate on him to cool his temperature.

Perceptions of and experiences with child immunizationPerceptions and experiences with regard to havingchildren vaccinated were explored in several ways dur-ing the FGDs and interviews. Thematic areas includeddecision-making within households related to childhealth and immunization, knowledge and previousexperiences with vaccines and immunization efforts inKenya, and perceived benefits of and constraints tochild immunization.


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Child health decision-making in householdsResults indicated that decision-making related to childvaccination varies. In the Coast region, parents said thedecision usually fell to the father or to another adultmale household member. In Busia, parents generallyagreed that mothers were the ones who usually decidedwhether or not to vaccinate a child:

It is the mother who mostly decides, because whenthey go to clinic, they are taught about various typesof vaccinations and their sequencing, including dates.(Participant, FGD older fathers, Bunyala, Busia)

Some study participants had more nuanced answers onthe question of who might decide whether or not to havea child vaccinated. They noted that in some instances, thefamily as a whole, including the extended family, may beinvolved in such a decision. In many situations, whomakes the decision may depend on who is the mainincome earner, how busy the mother is at home, and whocan provide transportation for the mother and child. Someparticipants noted that the family may also be influencedby a broader network of people that includes neighbors,community leaders, and health workers (see Table 3).Knowledge of local immunization programsIn general, parents were aware of local immunizationprograms and could name different diseases for whichchildren are vaccinated. Pharmacists were more knowl-edgeable than parents about these programs. Older andyounger men tended to demonstrate less knowledgeabout immunization programs than their male andfemale counterparts in the 25-49-year-old group.Benefits of vaccinationFocus group participants and in-depth interviewees inboth research settings generally reacted positively to theidea of having children vaccinated. For example, one ofthe chiefs interviewed explained that nothing he knewabout vaccines would deter him from accessing the ser-vices, and a women’s leader said she knew it was herresponsibility to take her child to be vaccinated. Similarviews were shared in FGDs with older women and

younger parents, who explained that they had not experi-enced major problems in accessing vaccination services.The majority of discussants held the view that the

main benefit of immunization was avoidance of disease-related child death and disability and reduction in theseverity of disease. Some participants said they under-stood that vaccines worked for a limited time, whileothers said that vaccines ensured that children did notget infections too frequently. Some misconceptionsamong parent FGD discussants included statements thatvaccines can cure diseases. In addition, communityhealth workers in one focus group in Busia reportedthat mothers sometimes confused vitamin A injections–given to babies during Malezi Bora (good nurturing)Week–with vaccination.Motivating factors related to immunizationMany of the perceived benefits of immunization werealso seen as motivating factors for getting children vac-cinated. Within this context, parents pointed to theirunderstanding that vaccines protected children fromspecific dreaded diseases. Parents in both the Coast andBusia regions also voiced appreciation for the healtheducation provided by service providers about vaccina-tion, and they welcomed the endorsement of influentialcommunity members, including chiefs and religious lea-ders. Some parents, particularly mothers, said that see-ing a health care provider for vaccination might providean added benefit to their children in the detection ofpreviously undiagnosed health problems.Constraints to child immunizationWhile parents were generally positive about Kenya’simmunization programs, they also provided insights intowhy some children may not get vaccinated. In thisregard, many pointed to a lack of understanding amongsome people of the benefits of vaccination:

There are those who if they are told that there is avaccine being given, they do not go. They say, “Whatis it for?” They do not understand what it is for,therefore do not let their children go for it. (Partici-pant, FGD fathers 50+, Kinango, Coast)

Table 3 Those likely to motivate others to access vaccination services

Primary influencers Secondary influencers

• Community health workers • Mothers-in-law

• Health care providers (doctors, nurses) • Grandmothers

• Neighbors • Councils of elders

• Village elders • Traditional healers

• Mass media • School-going children

• Local or provincial government administrations (including chiefs and assistantchiefs)

• Mother-to-mother support groups•

• Ministry of Medical Services • Representatives of non-registered immigrants and nomadiccommunities

• Ministry of Public Health and Sanitation • The elite within society (professionals/professional organizations)


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A community health worker in Busia offered anotherperspective, pointing to the role of mothers-in-law:

They may argue their son (now father to her grand-son) was not vaccinated and yet he is strong andhealthy. (Participant, FGD community health work-ers, Butula, Busia)

Among constraints to immunization, parents in FGDsin both Busia and the Coast voiced a variety of concernsabout the potential side effects of vaccination and aboutperceived injection practices. Side effects described ascommon included soreness at the vaccination site andslight fevers, while serious side effects included abscessesat the vaccination site, which were attributed to poorinjection technique. Parents in both Busia and the Coastsaid that they preferred to be served by experienced ser-vice providers as opposed to “dressing staff,” and someparticipants said they were concerned that needles andsyringes were reused on different children. In a relatedconcern, several participants suggested that parents mayworry about taking children to be vaccinated becausethey fear the child might become infected with HIVthrough unsafe injection practices. Parents in Busia andthe Coast also highlighted fears that the governmentmay be using vaccines to sterilize young female childrenor to reduce the population.Certain traditional cultural practices may inhibit

timely immunization, especially with regard to vaccinesgiven soon after birth. In the Busia region, study partici-pants reported that mothers who deliver at home arerequired to keep the baby indoors for three to four daysafter birth (three days for a girl, four days for a boy). Inaddition, some mothers do not like their children to beweighed naked during a check-up or to have them sharethe weighing basket with others. Study participantsnoted that some religious denominations also forbidchildhood immunization.Complaints about access to vaccine services were voiced byparents in both Busia and the CoastWhile parents could list places where children could bevaccinated, some felt that clinic services were at timesdifficult to access. Some also said they did not get suffi-cient advance notice about vaccination days. Parentsand other caregivers also complained of the inconveni-ence of traveling to a clinic and then waiting for hoursonly to be told that services were not available becauseof stockouts of vaccines and other drugs. For their part,many service providers interviewed said they weresometimes unwilling to open vaccine vials with shortexpiration dates if there were not enough children touse all the doses.The perceived attitudes of some service providers

toward patients also appeared to affect willingness to

attend a clinic. Some parents were reportedly concernedthat they could be criticized for not dressing their chil-dren well, for following traditional health practices, orfor having babies wear items to protect them againstharm. Young fathers in Busia Township explained thatdirty clothes worn by a child or mother or failure tocover a baby with a shawl sometimes elicited criticismfrom service providers. Several mothers also feared thatthey would not be welcome at vaccination centersif they had not shown up for antenatal care or hadnot delivered their babies at a clinic.Participants in several parent FGDs suggested that

some women seemed to be the focus of negative reac-tions at vaccination centers for reasons that had to dowith their parenting choices. Reports of some mothersbeing scolded by health care providers or even otherwomen for having given birth at close intervals, for hav-ing several children to vaccinate at the same time, or forbeing pregnant while still breastfeeding were heard dur-ing FGDs with parents in all age groups and settings.For mothers in Samia, being pregnant past the age of 45was said to elicit frowns and scorn at vaccinationcenters.For their part, service providers spoke of feelings of

frustration when parents did not come in for vaccina-tion. Such frustration could lead to unfriendliness orscolding. Some providers and many parents describedfamilies who had not taken their children to be immu-nized as “lazy,” “ignorant,” or “difficult.” A Busia healthworker captured the frustrations of other health careproviders:

They are careless parents. Continued visitation oreducation through a close friend will help changethem. Such parents do not have proper knowledge ofthe benefits of vaccines. Education should be donethrough local barazas (formal open meetings calledby local area chiefs and other administrators) andchurches for them, to help protect the life of the inno-cent child. (Participant, FGD community healthworkers, Butula, Busia)

Parents’ instinctive calculation of opportunity costsand benefits often influences whether or not they taketheir children to be vaccinated. A closer look at thestudy data indicates that parents, particularly womenin the Coast region, are strongly motivated when vac-cinations are free, when no payments are required atthe clinic, and when incentives, such as bed nets, areprovided. For some mothers in Busia, the real motiva-tion is not that the child should be vaccinated, butrather the desire for bed nets, food, milk, or otherfree goods provided as incentives during vaccinationsessions.


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Future malaria vaccines: issues and concernsDuring FGDs, key informant interviews, and clinic exitinterviews, field researchers oriented participants onprogress in malaria vaccine development and askedthem to respond to the prospect of a malaria vaccine.By and large, participants were excited about the poten-tial of a malaria vaccine, with no major differencesfound by region, gender, or age group. At the sametime, questions and concerns surfaced.Reactions to the possibility of a malaria vaccineResponses generally reflected the view that a malariavaccine would bring added health benefits. Many partici-pants, including district health officers, noted that com-munities would welcome such a vaccine if it were easilyaccessible. In many discussions, parents did not see aproblem with a new vaccine “fitting in” with existingcontrol measures. Parent discussants commonly held theview that reductions in the number and severity ofmalaria cases would indicate that a vaccine was working.These comments by a Busia father and a Coast mothersum up some of the reactions:

It will complement the existing interventions. Thevaccine, net, and cleanliness should be combined tofight malaria. (Participant, FGD fathers 50+,Bunyala, Busia)There is a lot of malaria in Kinango, especially nowduring the rainy season.... Therefore, if that vaccinecomes, all of us will feel some relief. And we arereally eager for it! [Laughter] (Participant, FGDmothers 25-49, Kinango, Coast)

Specific questions and concernsParticipants also expressed concerns and raised ques-tions about a malaria vaccine. Some parents worriedthat introduction of a vaccine could signal that currentmalaria drugs were no longer effective. Others won-dered whether the availability of a vaccine could reducethe need for bed nets. Some participants were moreguarded in their response to the possibility of a malariavaccine, suggesting that whether or not they acceptedone would depend both on the advice they receivedfrom service providers (collectively referred to as “doc-tors”) and on what they observed about the vaccine’seffectiveness. In many discussions, parents said theywould want to know where a vaccine was tested, onwhom, and what had become of those on whom it wastested. Many responses suggested that vaccine develo-pers should target everyone, including pregnant womenand the elderly and that such a vaccine should bedelivered orally. Commonly asked questions includedhow a vaccine would work in the body, when it wouldbe introduced, and whether it would treat or preventmalaria (see Table 4).

Expectations for a new vaccineIn brainstorming about what they would like from amalaria vaccine, FGD participants emphasized the ideaof protection, which they said should be more beneficialthan the protection afforded through existing malariainterventions. Judging from the data, there was a generalexpectation that the protection would last at least sixmonths; whereas for some, the vaccine should have alife-long effect. In some discussions, the view that com-munities would not mind the introduction of a partiallyefficacious vaccine was evident. One service providernoted that most vaccines did not have 100 percent effi-cacy. Another viewpoint held that as long as a vaccineboosted people’s immunity (including children’s), per-centages would not matter. One provider summed upthis view in the following way:

I don’t think they would mind.... [People are nothighly educated and] describing the percentage is notviable, as long as the child has been immunized....Even if the efficacy is low, I do not think there will be

Table 4 Information needs related to a future malariavaccine

Information requested by all participants

• Malaria prevalence rates.

• Expected benefits of the vaccine.

• Whether the vaccine would prevent or cure disease.

• Whether the vaccine would provide complete or partial protection.

• Number of doses needed.

• Mode of administration.

• Possible side effects of the vaccine.

• How the vaccine would work; how it would differ from other vaccinesin use.

• Whether the vaccine would be for children only or for pregnantwomen and others as well.

• Ages of children to be vaccinated.

• Duration of protection and need for booster doses.

• Whether the vaccine would be offered at anytime or only duringmalaria outbreaks.

• Where vaccinations would take place.

• Whether people would have to pay for the vaccine.

• Whether vaccination would be accompanied by incentives (such asbed nets).

• Manufacturer of the vaccine.

• Where and when the vaccine was tested and the outcome.

• Whether the vaccine was the result of a governmental ornongovernmental initiative and which governments support it.

Information requested by health workers only

• How to administer the vaccine.

• Dosage.

• Vaccine storage and handling requirements.

• Expiry date.


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a problem with the uptake. (District Medical Officerof Health, key informant interview, Coast)

Equally numerous, however, were those voices sug-gesting that a vaccine that is only partly efficaciouscould be negatively received by the community. Com-ments reflecting this view were observed across all studygroups. The data suggest that many participants inter-preted the concept of efficacy in terms of a “weak” or“strong” vaccine. For example, a health administrator inthe Busia region said:

The idea of a vaccine that is not strong or effectiveenough will discourage people from accessing the ser-vice for fear of being harmed by the vaccine. (Healthadministrator, key informant interview, Busia)

Similarly, a father in Mombasa stated:

If you show us the weakness of the vaccine, then wewill feel cheated and ignore it. (Participant, FGDfathers 25-49, Mombasa, Coast)

Concerns around affordability of a new vaccine sur-faced in many parent discussions. Even though there isno charge for vaccines in Kenya, participants discussedaffordability within the context of expenses related toclinic visits; for example, transportation to and fromhealth facilities and unofficial charges for services atclinics. Many participants said they felt that a malariavaccine should be free and that its adoption should helphouseholds to reduce expenses through a reduction inmalaria-related illnesses. Participants noted that accessto a malaria vaccine should be easy and that it shouldbe given at the same time as other childhood immuniza-tions. Others hoped that a malaria vaccine would beavailable at all health facilities and that patients wouldreceive milk or other incentives following vaccination.Such suggestions were noted more commonly in groupdiscussions in the Coast region.Some participants voiced strong opinions on the need

to see community health workers work hand in handwith service providers to reduce clinic workloads andwait times. Other ideas reflected the desire for broadercommunity involvement in vaccination campaigns. Forexample, young parents (particularly in the Coastregion) voiced a desire to be involved in campaigns fora new vaccine.

DiscussionFindings of this study support the view long held by healtheconomists [22] and more recently by leading social scien-tists that introducing a health intervention does not, on itsown, guarantee acceptance by communities. In the case of

a vaccine, acceptance may depend on a number of factorsthat, if not addressed, may result in suboptimal immuniza-tion coverage [8,10,14,23-26]. Some of these factors mayconstitute potential constraints to vaccination, whileothers could potentially enable or motivate those whoinfluence vaccine use. Still other factors relate to gaps ininformation about the intervention or the disease. Thefindings of this study highlight the importance of under-standing these kinds of sociocultural and health communi-cations issues related to existing malaria interventions andto vaccination [10,13] in order to inform a communica-tions strategy and policy decisions regarding vaccineintroduction.

Potential constraining factorsA clear set of issues emerged from this study as poten-tial constraints to vaccination. Some issues relate to theoverall quality of services at health facilities (congestion,delays, and the perceived attitudes of some service pro-viders) and highlight the critical need to fast-track skills-building related to customer care, especially in light ofincreased community awareness of an individual’s rightsto health [8,13,27]. Studies have shown that sustainedlevels of vaccination coverage are only possible whenthe quality of services is perceived to be good [13,15]. Infact, several studies over the past decade have shownthat persistent demand for improved vaccination deliv-ery services exists worldwide [10,28]. Concerns aboutvaccine side effects within the context of concerns aboutthe health and development of a young child also wereraised by parents in this study, and have been heardamong parents in other low-resource settings [10,14,15].

Potential motivating factorsParticipants strongly underscored the roles played bycertain community members and health care workers asboth providers of health-related information and asendorsers of vaccination services. Of particular signifi-cance is the potentially influential role of the communityhealth worker, who is viewed as an extension of thehealth delivery system under Kenya’s new communityhealth strategy. In addition, District Medical Officers ofHealth explained that health service providers werehighly regarded by the community and could be keyinfluencers, particularly in communities with low levelsof health awareness and literacy.

Information gapsA well-designed communications strategy would beessential to fostering a supportive environment for aneventual malaria vaccine. Effective communicationwould highlight the characteristics of the new inter-vention, address community questions and concernsprior to introduction, and build trust in vaccination


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[9,15,21,29-34]. The strategy would include key mes-sages (addressing information needs as well as potentialmotivating and constraining factors with regard to vac-cine use), and it would outline effective ways to deliverthese messages through information channels to identi-fied target audiences.

Key messagesResults suggest that while there is much on which tobuild in terms of current knowledge of the malaria bur-den and the generally positive image of immunization,additional information needs exist:

• The finding that fever may be equated with malariaand that other illnesses with fever as a symptom maybe seen as malaria should be addressed. This findinghas implications for how communities may even-tually judge future malaria vaccine efficacy as well asefficacy of current malaria control methods.• Specific messaging should highlight the potentialrole of a vaccine within a comprehensive malaria con-trol strategy. This should help to address concernsthat malaria vaccine introduction would be perceivedas obviating the need for other malaria interventions.• Managing expectations about a new vaccine shouldbe a key aspect of a communications strategy. Parti-cipants articulated many unrealistic expectations andassumptions about what an eventual malaria vaccinemight offer.• Specific information about a malaria vaccineshould be provided. Information needs identifiedrelate to how a new vaccine would work, its safetyprofile, duration of protection, when and where toaccess the vaccine, and target age groups.• Key messages should aim to strengthen interac-tions between service providers and communitymembers, including younger and older parents andthose less economically privileged.• Messages should consider “hidden” costs identifiedwithin communities, such as transportation chargesand unofficial fees for services, as these couldaffect the perception of whether or not a vaccine isaffordable.

Target audiencesThe results show that parents and other caregivers ofchildren often are influenced by a broad network ofpeople within communities in making decisions aroundchildhood vaccination. This suggests that a communica-tions strategy supporting vaccine introduction shouldtarget men as well as women, community and healthworkers, and political, civic, and religious leaders.

Information channelsCommunity health workers, traditional healers, andhealth care providers emerged as some of the trustedsources and key influencers within the communities andshould be considered as important channels for healthcommunication. Shopkeepers and herbalists should alsobe considered.

Study limitationsThis study has several important caveats to be kept inmind. To meet the study aims, an exploratory, qualita-tive approach was employed using criterion-based sam-pling techniques entailing a small yet carefully selectedsample. The merits of this study should, therefore, bejudged according to standards appropriate for qualitativeresearch. The findings reflect the experiences of com-munities located in two regions of Kenya only, the Busiaand South Coast regions of Coast and Western Pro-vinces. In either case, it is not appropriate to generalizefindings to the entire Kenyan population.

ConclusionsAs Kenyan policymakers gather data for decisions onpossible malaria vaccine introduction, a number of fac-tors should be considered. First, study participantsunderstand that malaria is a serious problem and thatno single tool can control the disease. Communitiestherefore welcome the prospect of a vaccine againstmalaria, although they would have questions and con-cerns about the potential of the new intervention. It isalso noteworthy that when deciding whether or not tohave their children vaccinated, parents weigh a numberof factors, including personal opportunity costs, resourceconstraints, and perceived benefits.The study raises other important points that can

inform both a well-grounded communications strategyand policy decisions, should a malaria vaccine becomeavailable for use. For instance, while a strong apprecia-tion for local child immunization programs exists, parti-cipants have concerns about the quality of servicesoffered and have ideas about how they can improve.Such views do not reflect serious dissatisfaction; rather,they represent empowered communities who worry thattoo many children have yet to be reached with immuni-zation services. Finally, targeted health systems strength-ening–particularly as it affects interactions betweenhealth care providers and community members–shouldbe addressed.

AcknowledgementsThe core team that conducted this study was led by the followingmembers: Dr. David I. Ojakaa (Principal Investigator), and Yvonne W. Machira,Peter Ofware, and Emmanuel Yamo (Co-investigators). The team is gratefulto a number of individuals and institutions that provided the necessary


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support during various stages of this study: Dr. Festus Ilako (Deputy CountryDirector) for medical and clinical perspectives; the PATH team for overalltechnical guidance; the AMREF Ethics and Scientific Review Committee forthe approval; the Ministries of Public Health and Sanitation in Nairobi, CoastProvince, and Western Province for direction; the Division of Malaria Control;the Division of Vaccines and Immunization; AMREF Coast and Busia fieldoffice staff; the seven research assistants and the drivers; Data AnalystsFrancis Njiri and Purity Njagi; and AMREF Administrative Assistant Rose Muli.

Author details1African Medical and Research Foundation, Wilson Airport, Langata Road, POBox 30125, Nairobi, Kenya. 2Previous address: African Medical and ResearchFoundation, Wilson Airport, Langata Road, PO Box 30125, Nairobi, Kenya.3PATH Malaria Vaccine Initiative, 455 Massachusetts Avenue NW, Washington,DC 20001-2621, USA. 4PATH Malaria Vaccine Initiative, ACS Plaza, 4th floor,Lenana and Galana Road, PO Box 76634, Nairobi 00508, Kenya. 5PATH, 2201Westlake Avenue, Suite 200, Seattle, WA 98121, USA.

Authors’ contributionsDIO (Principal Investigator) was responsible for overall study design,management, analysis, and writing. YWM, PO, and EY (Co-investigators) wereequally responsible for the design, management, and analysis in the study.ABN, AB, YC, and PV provided technical oversight to the study, whichincluded reviewing the protocol, data quality checks, and reviewing as wellas writing parts of the manuscript. All authors read and approved the finalmanuscript.

Competing interestsThe authors declare that they have no competing interests.

Received: 12 March 2011 Accepted: 30 May 2011Published: 30 May 2011

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doi:10.1186/1475-2875-10-147Cite this article as: Ojakaa et al.: Community perceptions of malaria andvaccines in the South Coast and Busia regions of Kenya. Malaria Journal2011 10:147.


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http://www.malariavaccine.org//files/March182011MVIfactsheet_backgrounder.pdf

http://www.malariavaccine.org//files/March182011MVIfactsheet_backgrounder.pdf

http://www.ncbi.nlm.nih.gov/pubmed/10067669?dopt=Abstract


http://www.malariavaccine.org/malvac-roadmap.php

http://www.malariavaccine.org/malvac-roadmap.php

http://www.malvacdecision.net/index.html

http://www.malvacdecision.net/index.html
















http://www.nmcp.or.ke/section.asp?ID=3

http://www.nmcp.or.ke/section.asp?ID=3
















Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya

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