This is one of the first studies to evaluate attitudes about influenza infection and vaccine in low-income urban and rural communities in sub-Saharan Africa. The study contains useful information for those considering future vaccination efforts. The relatively high acceptance of free influenza vaccine in these two communities is encouraging, and suggests that acceptance would not be a barrier to introducing seasonal influenza vaccine on a broader scale in Kenya. One reason for the high acceptance may relate to the appreciation and acceptance of vaccines in general in Kenya and the fact that the vaccine was offered free of charge. Many respondents said their children had received many non- influenza routine vaccines in the past.
Before the vaccination campaign, respondents who were not planning to get their child vaccinated mainly cited concerns about vaccine safety and efficacy and interest in receiving more information. Group discussion participants raised concerns about vaccine safety and efficacy. Other studies assessing parental attitudes towards childhood vaccination have demonstrated that other parents have raised similar concerns [16–18]. A survey of healthcare workers in Kenya prior to a pandemic H1N1 vaccine campaign found concerns about vaccine side effects were a barrier to vaccination . In the remaining two years of our vaccine effectiveness campaign, and in future vaccine campaigns in vaccine-naive communities, strong efforts should be made to educate parents about the very low side effect profile of trivalent seasonal influenza vaccine [20, 21].
In interviews conducted after the vaccination campaign, many parents of non-vaccinated children said they did not get their child vaccinated because they were too busy to take their child to the vaccination centers, their child was away or the vaccination hours were inconvenient. We did not use any schools as vaccination centers because all schools in the two PBIDS sites included non-PBIDS residents, and the vaccine supply for this project was limited. Future influenza vaccine campaigns should consider using primary schools as vaccination sites.
Respondents expressed a wide range of opinions about the causes of and treatments for influenza virus infection. In the pre-vaccination discussions, participants cited low ambient temperatures, dust, dirt, and smoke among causes of influenza. Although the former has been shown to be associated with influenza transmission globally [22, 23], the latter three factors have not. However, the mention of dust and dirt could reflect an understanding that poor hygiene and indoor air pollution (i.e. from cooking) could lead to increased disease transmission. In addition, respondents mentioned traditional liquor, hot water, hot lemon solution, and ginger and garlic solutions as remedies for influenza. Oseltamivir, which costs at least US $30 for a treatment course at pharmacies in Kenya, would rarely be affordable for Kibera and Lwak residents.
Some residents said they would not vaccinate their children because they doubted the potential severity of influenza and therefore the need for a vaccine. Influenza has been shown to cause severe disease and death in children in the US and other countries [24–27] and pandemic H1N1 influenza caused hospitalizations and deaths in Kenya and other countries in sub-Saharan Africa . Results from influenza surveillance systems in Kenya and other Sub-Saharan African countries are beginning to shed light on the role of influenza in morbidity and mortality in Sub-Saharan Africa ; communicating the data, when it is available, to the general public to put influenza burden in proper perspective, may impact demand for vaccination.
Our surveys had limitations. They were conducted in two relatively small communities, so the findings may not be generalizable to the whole country. However, we included low-income rural and urban communities in large population areas, and these populations are likely similar to much of the country. Second, participants were people enrolled in the KEMRI/CDC PBIDS, and their attitudes towards the overall surveillance system may have affected their attitudes towards the vaccine. Third, we did not provide an option to write responses under the “other” category to the question, “Why will you not have your child get the flu vaccine?” in the pre-vaccination questionnaire, and yet we ended up with many respondents choosing the “other” response. Fourth, the number of persons eligible to be interviewed significantly dropped during post-survey especially in Lwak. We suspect that because Lwak is a rural agricultural area, more primary caretakers were away from the homesteads conducting farming-related activities during the post-vaccine interview period. Finally, because of the design of our survey we could not evaluate the effectiveness of the awareness campaign that was conducted before the vaccine campaign. Despite these limitations, our findings offer insights into how parents made decisions to vaccinate their children in two diverse communities in Kenya.