"When You Are Injected, the Baby Is Protected:" Assessing the Acceptability of a Maternal Tdap Vaccine based on Mothers' Knowledge, Attitudes, and Beliefs of Pertussis and Vaccinations in Lusaka, Zambia

Severe and fatal pertussis (whooping cough) infections are concentrated among infants who are too young to be protected through routine vaccinations; the disease is pervasive in Zambia and other low and middle-income countries (LMICs). Maternal Tdap (mTdap) is considered to be an effective way to address this gap in preventative care. To inform strategies for mTdap implementation in low-resource settings, these public health researchers sought to understand knowledge, attitudes, and beliefs toward pertussis and maternal vaccines and assess the barriers to vaccine acceptance.

Embedded within a larger research project, the Southern Africa Mother Infant Pertussis Study (SAMIPS), this qualitative analysis involved focus group discussions (FGDs) with mothers in Lusaka, Zambia, in January 2016 at the Chawama Clinic, which serves a low-income population. Fifty mothers participated across 7 FGDs.

Mothers had limited knowledge of pertussis and vaccines. Despite limited knowledge of the causes of whooping cough, mothers demonstrated a strong understanding of the danger it posed to their children's health. The majority of mothers described vaccines as medicines designed to protect their children from dangerous diseases, and viewed them as supportive to overall health. Only a small minority of women in the FGDs expressed concerns, which were mostly related to the vaccine not protecting the mother. Mothers also highlighted barriers and facilitators to vaccine uptake, which included:

• Male partner involvement in child healthcare - a supportive partner facilitates access to healthcare, while a hesitant one could inhibit it.
• Feelings of maternal authority over healthcare decision-making - many women felt a personal authority over healthcare decision-making, expressing that it was their role to care for their child through clinic care, despite contrary familial opinions.
• Community rumours, such as those surrounding Western medicine and its connection to Satanism, and misinformation. One mother noted that anecdotal fears in the community about adverse events from vaccines have prevented families from profiting from the beneficial aspects of vaccines. Women noted that increased outreach between health professionals and the larger community helps to address these knowledge gaps.

The researchers observed that the mothers conveyed an enthusiasm, rather than hesitancy, for maternal vaccines, suggesting that mTdap would be supported as long as healthcare professionals indicate the benefits to child health. They point to the need to approach immunisation in culturally sensitive ways to correct any misconceptions and alleviate concerns. There is community support for educational initiatives such as Child Health Week, which has proven to be successful in Zambia not only in terms of vaccination rates, but also, as detailed in this research, in terms of acceptability. Along those lines: "National immunization leaders should be aware of the importance of community sensitization as a useful tool to increase vaccine acceptability. Literature on health promotion efforts reveals that education and awareness initiatives are helpful to improving knowledge of the Tdap vaccine and reducing vaccine hesitancy....Applying this to the Zambian context, culturally-sensitive vaccination campaigns, already a standard in the Zambian health promotion tool kit, could encourage maternal immunization amongst Zambian women if mTdap vaccine were introduced."