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Stories from the Field


A question of trust: reasons for refusals revealed by DR Congo study

Overt and covert refusals contribute to as many as four out of ten missed children in DR Congo, one of the highest rates globally. As part of ongoing efforts to mobilize parents against polio, a key UNICEF led study has helped reveal the complex social, cultural and religious reasons why children continue to be missed during immunization campaigns in the country.


UNICEF/2012/P. Flynn
A woman from Katanga overtly refuses the polio vaccine as a result of her
strong religious beliefs and distrust in the vaccine due to previous forced
vaccinations in the region.

“We don’t trust the vaccine; we have faith in God who heals us. We trust in God,” says Maman Adèle in Katanga. Issues of trust are at the heart of DR Congo’s high polio vaccine refusal rates, with a recent study suggesting that overt and covert refusals together may account for as many of 40% of children missed.

Currently around one in ten children under-5 goes unprotected against polio during each of DR Congo’s monthly polio vaccination campaigns. In a vast country with few roads and fractured health systems each polio campaign is a massive logistical operation. It is therefore a major concern that so many children still go unvaccinated, even when the vaccine has reached their door.


Understanding refusals

According to Independent Monitoring data, ‘refusals and’ child absence’ continue to be the two main reasons why children are missed. In the first quarter of 2012, approximately 46% of missed children were not vaccinated due to refusal, and 35% were due to child absence. In the capital Kinshasa, parents openly refusing the vaccine.  In other provinces, high rates of child absence often mask a fear of reprisals from authorities for openly refusing OPV.

These findings have emerged from  a study conducted by UNICEF-supported anthropologist, Veronique Goblet, and the Kinshasa School of Public Health in October 2011. The study focused on children missed by the October campaign in the five provinces that reported polio cases in 2011: Kinshasa, Bas Congo, Bandundu, Katanga, and Kasai Occidental. With the findings ‘typical’  rather than ‘representative’, the qualitative study explored the social factors contributing to missed children – such as the credibility and quality of information parents receive about polio, risk perceptions and motivations for vaccination. Over three-hundred parents were interviewed, and 32 focus group discussions were held with community influencers, healthcare workers and programme staff in the field.


UNICEF/2012/P. Flynn
Religious Leader Marco Kiabuta preaches to his
followers to refuse vaccinations in the Mukwaka village,
Katanga Province.

The battle to win trust


So why do caregivers refuse polio vaccine when it is the only way to effectively protect their children from the devastating effects of the disease?

Rumours emerged from the study as the main barrier to parents not vaccinating their children. With polio cases now so few, many parents fear the vaccine more than they fear the disease, a situation that provides fertile ground for rumours to spread. “Taking the vaccine does not guarantee that the disease will be eliminated. It could be a trick on the part of white people who have realized that black people are very intelligent, that our minds are sharp,” says Papa Raph, from Kasai Occidental. It is also believed that a child who is sleeping, sick, or has not eaten should not be vaccinated - that ‘medicine’ given to a hungry child will weaken them further. Such traditional beliefs add to the common conviction that all protection comes from God or the ancestors, and that man alone cannot cure diseases.


Forced vaccination, a practice that was common in colonial times, only helps fuel rumours and distrust. By contrast, routine vaccination offered at child health sessions organized by UNICEF and other NGO's have gained the locals’ trust over the years and are a good opportunity to reach missed children: 75% of children in this study, both missed and vaccinated had received routine polio immunization.


Katanga’s challenges


Northern Katanga is one area that presents the programme with some unique challenges. Only 8% of children covered by the study in the Province were routinely vaccinated. Independent Monitoring recorded refusals as high as 60% of missed children in January, falling to 41% in March. Coercion during campaigns is largely to blame: with 50% of guardians in Katanga reporting that their children had been forcibly vaccinated in the past as compared to 7% of guardians nationwide.


UNICEF/2012/P. Flynn
The difficulties in delivering OPV can be seen by the roads to reach remote
districts and villages.

Religious groups also play a role in overt refusals: one third of caregivers interviewed in Katanga say their church forbids vaccination. In January, UNICEF communications staff met with leaders of the country’s most resistant religious groups: Kitawala Philadelphie, Watch Tower Bible, Postolo, and the Church of Blacks in Africa (Église des Noirs en Afrique). The meetingresulted in a breakthrough, with threegroups agreeing to comply with vaccinationcampaigns. Some continued to refuseactively, while others wished to consultwith their communities before makinga decision. More work is needed, but progress is being made.


Engaging religious leaders from these resistant churches will be crucial for success but must be done with care. Vaccinators must be respectful of caregivers’ traditional and religious beliefs as well as skilled at addressing fears and reassuring parents about the safety of the vaccine.


With higher trust in routine services, a campaign strategy centered around health posts should be considered, in particular for Katanga, where offering vaccine at key fixed locations could also help reach children of migrant workers. These workers and their families often travel long distances to find work accounting for large numbers of children missed every campaign.


UNICEF/2012/P. Flynn
The social mobilizer meets with the family to discuss the benefits of OPV and
their resistance.

Towards a polio-free DRC


For polio eradication to succeed in DR Congo, the programme must not only overcome the many logistical and operational challenges, but also understand the complex social reasons why children are missed. Religious and traditional beliefs, political distrust, rumours about OPV safety, poor vaccinator communication skills all contribute significantly  to children being missed. As is the case in other countries where religion and traditional beliefs drive refusals, UNICEF and its partners are engaging with religious and traditional leaders to initiate the dialogue of trust that is vital for bringing a polio-free future to DR Congo’s children.

The full study on social reasons for missed children will be available online in July.

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