Factors Influencing Attitudes Towards a Novel TB Vaccination or BCG Revaccination in Mozambique Restricted; Files Only

Abstract

Tuberculosis (TB) has persisted as the leading infectious cause of death globally,

resulting in 10.6 million cases and 1.3 million deaths in 2022. New TB vaccines for

adults and adolescents are in development, with at least 1 in phase 3 trials. As a high-

burden country (361 per 100,000 incidence), Mozambique is one of the first countries

where a new TB vaccine would be introduced. However, vaccine hesitancy towards

new TB vaccines could limit their public health impact. We sought to evaluate drivers

of vaccination behavior among adults, adolescents, and their caretakers in Manhiça,

Mozambique. The study consisted of 249 cross-sectional surveys, of which a subset of

23 individuals participated in in-depth interviews. A thematic analysis was conducted

utilizing the adult and caretaker data, while adolescent data was used to triangulate

subsequent findings due to its lower saturation. Themes included health literacy as a

driver of vaccination, perceptions and experience with vaccine safety and effectiveness

influencing TB vaccine confidence or preference, trust in health systems driving vaccine

confidence, and social processes and norms guiding health-related decision-making and

vaccination intent. Our findings suggest that information about TB vaccines and

individual health literacy would be primary drivers of motivation to receive a novel TB

vaccine or a BCG booster in Manhiça. Participants often sought out or expressed a need

for further information about a vaccine’s purpose, safety, and function. Hospitals,

clinics, and other facets of the local health system were frequently cited as trusted

sources of health information or locations to receive vaccinations. Sharing of

information and personal experiences was also perceived as a successful driver of

motivation to vaccinate. Adults and caretakers shared similar perspectives across all

themes, though caretakers expressed slightly more hesitancy regarding vaccine function

and safety. Adolescents were heavily accepting of novel TB vaccinations and BCG

revaccination but frequently noted a preference to seek decision-making support from

their caretakers. Thus, decision aids and other informative measures may be worth

exploring to promote TB vaccination uptake, in addition to interpersonal sharing of

information or other social influences.

Table of Contents

Literature Review ........................................................................................................................ 1

Background & Epidemiology of Tuberculosis ................................................................................... 1

TB in Mozambique ................................................................................................................................ 2

Vaccinations for Tuberculosis ............................................................................................................. 3

Vaccine Hesitancy .................................................................................................................................. 4

Hesitancy Towards New Vaccinations: HPV & COVID-19 ........................................................... 6

Vaccine Hesitancy Towards TB .......................................................................................................... 7

Introduction ................................................................................................................................ 10

Methods ....................................................................................................................................... 12

Data Collection & Sample Population ............................................................................................ 12

Data Exploration & Analysis ............................................................................................................ 13

Results ......................................................................................................................................... 16

Survey responses across interviewed sample .................................................................................. 16

Theme overview .................................................................................................................................... 21

Health literacy as a driver of vaccination ........................................................................................................... 21

Perceptions and experience with vaccine safety and effectiveness influencing TB vaccine confidence or

preference ............................................................................................................................................................ 23

Trust in health systems driving vaccine confidence ........................................................................................... 24

Social processes and norms guiding health-related decision-making and vaccination intent ........................... 25

Adolescent responses ........................................................................................................................... 28

Health literacy as a driver of vaccination ........................................................................................................... 28

Perceptions and experience with vaccine safety and effectiveness influencing TB vaccine confidence or

preference ............................................................................................................................................................ 28

Trust in health systems driving vaccine confidence ........................................................................................... 29

Social processes and norms guiding health-related decision-making and vaccination intent ........................... 29

Discussion ................................................................................................................................... 30

Behavioral & Social Drivers Framework Linkage ......................................................................... 31

Limitations ........................................................................................................................................... 32

References .................................................................................................................................... 34

Appendix ...................................................................................................................................... 40

About this Master's Thesis

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Keyword	Thematic Analysis Vaccine Hesitancy Tuberculosis TB Vaccination
Committee Chair / Thesis Advisor	Kristin N. Nelson, Emory University

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