Root causes of refusals revealed through DR Congo study

Examining one of the reasons children are missed during vaccination.

A woman from Katanga overtly refuses the polio vaccine as a result of herstrong religious beliefs and distrust in the vaccine due to previous forcedvaccinations in the region. UNICEF DRC/V. Petit

Deeply entrenched religious and traditional beliefs as well as a strong distrust of government health services undermine polio eradication efforts, particularly in Katanga

“We don’t trust the vaccine; we have faith in God who heals us. We trust in God,” says Maman Adèle in Katanga. A profound belief in divine intervention against polio, among many other religious and cultural beliefs, contributes to DR Congo’s high proportion of children who are unvaccinated due to parents’ refusal of the oral polio vaccine. Between 8-12% of children under-5 years old are left unvaccinated against the poliovirus after each of DR Congo’s polio vaccination campaigns, occurring almost monthly.

There could be many reasons for unimmunized children in DR Congo – vaccination teams may not have arrived at their designated households – either due to poor performance or logistical constraints; when teams do arrive, parents may refuse the vaccine; or they may inform front-line workers that children are not at home when they arrive. Among children that are missed each month, up to 40% are missed due to their parents’ refusal to accept the oral polio vaccine.

With 70 million people spanning a vast territory the size of Western Europe, a wide array of geographic, security and political challenges make DR Congo a particularly challenging context for polio eradication. A deeply entrenched social and cultural system that rejects ‘western medicine’ compounds the eradication effort in some of the highest risk areas.
To better understand the social norms underlying vaccine refusal, UNICEF has led a study to investigate the social reasons that explain why children continue to be missed during immunization campaigns.

Understanding refusals


Religious Leader Marco Kiabuta reaches to his followers to refuse vaccinations in the Mukwaka village, Katanga Province.

According to Independent Monitoring data, two main reasons contribute most to children not receiving OPV regularly in DR Congo- refusals and children’s absence. 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 some cases, reporting of child absence has been found to conceal vaccine avoidance behaviour, rooted in religious beliefs or distrust of government health services. In Kinshasa, parents who don’t want to give their children OPV are fairly outspoken in openly refusing it. But in other provinces, where children seem to be missed largely because they were absent at the time teams’ visited, and caregivers claim that they will accept vaccination during the next round, this willingness has been found to conceal a fear of reprisals from authorities for openly refusing OPV.

These findings and more have emerged from an October 2011 study led by a UNICEF-supported anthropologist, Veronique Goblet, and the Kinshasa School of Public Health.

While these beliefs also affect perceptions of routine vaccination in Katanga, where only 8% of children in this study were vaccinated, there was greater trust in routine services. Over a quarter of parents interviewed in Katanga said they have no issue with vaccinating their children at weigh-ins, where they can access other health services and where the decision to vaccinate is left solely to the child’s mother.

An OPV delivery strategy centred around health posts should be considered, in particular for Katanga, where reinforcing routine operations at key locations could also help reach children of migrant workers. These workers and their children sometimes travel over 100km to find work in farms, accounting for a large number of children missed at the household level.

Towards a polio-free DRC

For polio eradication to be successful in DR Congo, the programme must not only overcome logistical and operational challenges, but also understand the social reasons why children go unvaccinated. Religious and traditional beliefs, political distrust, rumours about OPV safety, and training of vaccinators on interpersonal skills are all key determinants of missed children in DR Congo. As is the case in other countries where religion and traditional beliefs drive refusals, UNICEF and its partners are engaging with religious leaders to initiate a dialogue that can bring a polio-free future to DR Congo’s children.

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