Making Vaccination “Easy” in Indonesia with Trusted Faces and Familiar Places

Above. Public performance groups reciting praises to the prophet in a highly stylized, choreographed fashion for the Maulid Feast in Aceh Province, Indonesia. Maulid is the celebration of the Prophet Muhammad's birthday and is very popular in Aceh, where people talk about a Maulid "season" rather than a month or day.

Vaccine misinformation on Indonesian social media, according to a recent study, clustered around three main concerns:

• halal certification of the vaccines,
• industrial conspiracies,
• possible side effects.

Public approval of childhood vaccines in low- and middle-income countries (LMICs) is generally strong. But regional variations in vaccine acceptance and uptake show inequities in vaccine access and potential variations in confidence. Unlike many LMICs, Indonesia actually has low vaccine coverage. Aceh province, on the northwest tip of Sumatra, has especially low coverage compared to other regions.

In Indonesia and in many other LMICs, the situation often boils down to two considerations:

• Do you have access to the vaccine?
• Do you trust the people recommending the vaccine?

An interdisciplinary team of researchers from the Universitas Syiah Kuala and the University of Michigan has co-designed a robust project to promote vaccine equity and uptake in Indonesia—Trusted Faces, Familiar Places.

"With our community outreach, the importance of vaccination will be continually reinforced in unusual locations.”
– Harapan, Universitas Syiah Kuala

Their goal is to offer a novel, sustainable model for future vaccination campaigns in which vaccines are a visible part of everyday community life. “In the traditional model, successful vaccination programs are invisible, because a prevented disease is an unseen disease,” said Harapan, a researcher at Universitas Syiah Kuala School of Medicine and co-PI on the project. “With our community outreach, the importance of vaccination will be continually reinforced in unusual locations.”

In Aceh province, coverage for pediatric measles vaccination hovers around 50%, the lowest of any province in Indonesia. A preliminary survey of 899 parents conducted by the project team found that completion of the recommended childhood vaccine series varies widely by access to clinics and comfort with information about the vaccines.

Public approaches to everything from healthcare to religious engagement can diverge widely across the archipelago nation of Indonesia—the world’s most populous Muslim-majority country. “Because vaccination programs are attached to the central government, most people in Aceh do not trust vaccines as a matter of course,” said Harapan. “Low trust of the government is related to low vaccine coverage.”

Additionally, Aceh is a region with a strong religious identity and has been granted more autonomy by the national government. So the project team is betting that incorporating religious life into the study design will increase vaccine uptake in the region. “In this project, we will try to reduce this hesitation by having religious leaders included in the vaccine program. We will train religious leaders alongside healthcare workers to take part in the project,” Harapan noted.

The findings from the team’s preliminary survey speak to several needs in Aceh. One insight is that accessing vaccine services is still a barrier: “almost certainly due to time conflicts and transportation access, since community health clinics are widely available, broadly speaking,” Harapan said.

Another finding is that barriers to vaccination are complex and involve many aspects of daily life, including religious beliefs.

Harapan summarizes the situation like this: “The mindset is that ‘vaccination is hard.’ You have to make a trip to a healthcare center. You have to maintain your vaccine schedule. You might have relatives and friends in the community who disagree with your decision. We want to challenge this paradigm and get people thinking that ‘vaccination is easy.’”

Above all, the findings from the preliminary survey revealed that a multipronged approach is necessary to improve vaccination rates in Aceh.

Combining Convenience and Community

To achieve this paradigm shift in how the public views and utilizes vaccination services, the project team will simultaneously address issues of trust and ease of access.

They will help mobilize religious leaders and communities to discuss vaccines openly, with the goal of countering reported lack of information about vaccines among unvaccinated families. And they will train more community health workers in vaccination and in physically delivering vaccines through a “vaccine-in-a-van” concept to facilitate ease in accessing vaccines.

“By mobilizing individuals in community settings where people live, work, worship, and learn, we can expand vaccine information and services,” said Abram Wagner, research assistant professor of Epidemiology and Global Public Health in the U-M School of Public Health and co-PI on the project. “Through community engagement, we believe we can promote a participatory process in multiple aspects of the immunization program so that the idea and reality of vaccination become more ingrained in the fabric of community life.”

Convenience

The familiar places part of the project is all about the mobile clinic model—or vaccines in a van—so important because of socioeconomic factors that impact access to healthcare facilities. “Many people in these communities have livelihoods tied to agricultural work, so they are in the field for much of the day. Most health clinics are open during weekdays. Clearly, this presents a problem for many,” said Wagner.

The van not only brings the vaccines themselves to these communities in locations much closer to their homes and during more convenient times. But the van staff “will provide information about the vaccines and will provide games for children so they have a positive experience,” noted Harapan.

Community

The trusted faces part is all about community, including local community health workers and local religious leaders and religious spaces.

For many Muslims, vaccination decisions can be more complicated than other public health measures because some vaccines are manufactured with haram (not permitted) ingredients, more specifically ingredients that are porcine in origin.

Daniel Birchok, associate professor of Anthropology at the University of Michigan–Flint, is an anthropologist of religion focusing on Islam in Southeast Asia and a co-investigator on the project. “Vaccines manufactured with halal (permitted) ingredients are allowed, and even vaccines made with haram ingredients are, according to some Muslim legal scholars, permitted—because the benefit of the vaccine for personal and communal health outweighs the ingesting of a miniscule amount of pork gelatin,” Birchok shared.

The project team will organize a conference in Aceh for both religious leaders and community health workers. “We will include formally trained imams but will also employ a grassroots approach to identify the community’s “informal” religious leaders, for example those who are present at many child-centric religious rituals and social events,” Harapan said. “The one- year birthday milestone, for example, is religiously and culturally important in Indonesia. Families often hire informal religious leaders to lead such ceremonies—circumcisions, weddings, memorials, holidays like the Prophet Muhammad’s birthday.”

Harapan says the team will know the project is working “if it is adopted by the national government and local leaders in key locations where the population is majority Muslim and if vaccines are accepted in the community at increased rates to our current baseline rates.”

Sustainable Networks

The Trusted Faces, Familiar Places project was awarded $826,700 from the U-M Center for Global Health Equity as part of the Center’s Global Vaccine Equity Initiative, due to its potential to shift how the Indonesian public views and utilizes vaccination services.

“The inclusion of faith leaders and community health workers in Indonesia to assist with both advocating for and administering infant and childhood vaccines holds out tremendous promise for increasing vaccine coverage,” said Matthew Boulton, Center associate director and senior associate dean for Global Public Health at the U-M School of Public Health. “Innovative approaches are desperately needed to reach the millions of children who are under- or unvaccinated each year.”

“This project builds on similar models in Pakistan, Afghanistan, and Palestine by inserting vaccination into diverse social spaces,” said Wagner. “We’re simultaneously ‘liberating’ vaccine administration from a clinic-based model while increasing convenient access to vaccines.”

Enlisting the assistance of respected religious figures and lay community workers in a community-centered mobile vaccination unit is a new twist. “The collaboration is rather unique, in large part because of the complexity of the project,” said Harapan. “We have vaccine and pediatrics experts from public health and medicine, economists and anthropologists from the humanities, and multiple team members with a deep understanding of local demographics and cultural factors that helped us refine our selection of location and other details that will impact the overall success of the project.”

Harapan appreciates how much project leads at Universitas Syiah Kuala and U-M are committed to taking all necessary steps to ensure an equitable and mutually-beneficial partnership: “Universitas Syiah Kuala and University of Michigan partners have had equal opportunities to engage in grant writing, project priorities, financial compensation, and other aspects of the grant. Both parties are actively involved in qualitative and quantitative research design. Indonesian partners are implementing the survey and have discretion in managing our budget to maximize efficiency and effectiveness.”

Deploying community members and trusted leaders to administer vaccines and provide counseling capitalizes on a different set of trusted social networks than those used in traditional clinician-patient relationships. “We believe this reframing and increased visibility, along with a training program that highlights vaccine hesitancy and cultural competency, will decrease population-level vaccine hesitancy,” Wagner said.

More than a one-time vaccination campaign, the team hopes to create a sustainable network that can be deployed repeatedly—at intervals consistent with recommended vaccine schedules—to maintain community health in Indonesia and protect everyone, especially children, from vaccine-preventable diseases.

–Josh Messner

Other members of the project team include Caroline Hogan (U-M Pediatrics), Ichsan (School of Medicine, Universitas Syiah Kuala), Rosaria Indah (School of Medicine, Universitas Syiah Kuala), Antonios Koumpias (Social Sciences, UM-Dearborn), Rahul Ladhania (U-M School of Public Health), Tita Menawati (School of Medicine, Universitas Syiah Kuala), Jason Pogue (U-M Clinical Pharmacy), Amanda Yufika (School of Medicine, Universitas Syiah Kuala).