Reaching the unreached through building trust: a mixed-method study on COVID-19 vaccination in rural Lao PDR

Abstract

Introduction: The global COVID-19 vaccine rollout has been impacted by socioeconomic disparities and vaccine hesitancy, but few studies examine reasons for changed attitudes. In Lao People's Democratic Republic (Lao PDR), a nationwide government-led initiative was developed in response to COVID-19, focused on community health ownership and trust in primary healthcare. The intervention team including health and governance sectors conducted capacity-building workshops with local staff and community representatives and visited villages for vaccination outreach. This study investigates the impact of this intervention on COVID-19 vaccine acceptance in rural communities.

Methods: Conducted in Xiengkhuang province, Lao PDR, from December 2022 to February 2023, the study employed a sequential mixed-methods research design. Data on vaccinated individuals from 25 villages were collected from 11 primary healthcare units; pre-post analysis was applied. Qualitative data, gathered through interviews and focus group discussions with villagers, village authorities, health staff and local government (n=102) in six villages, underwent inductive thematic analysis.

Results: First-dose vaccine uptake after the intervention increased significantly (6.9 times). Qualitative analysis identified key reasons for vaccination hesitancy: (1) mistrust due to rumours and past experiences; (2) poor communication and inconsistent messaging and (3) challenges in access for priority groups. Influencing factors during the intervention included (1) effective local-context communication; (2) leveraging existing community structures and influential individuals in a multisectoral approach and (3) increased community motivation through improved satisfaction, ownership and relationships.

Conclusion: This study highlights the impact and methods of building trust with unreached populations in health interventions, emphasising locally led solutions. Successful reversal of vaccine hesitancy was achieved by addressing root causes and fostering ownership at community and local government levels through a 'positive approach'. This diverges from conventional supplemental immunisation activities and holds potential for systematically building trust between unreached populations and health systems. Further research could explore the impacts of routine vaccination for sustained improvements in health equity.

Keywords: COVID-19; Prevention strategies; Qualitative study; Vaccines.

Figure 1

Map showing the location of the intervention and study area (source: UN Office for the Coordination of Humanitarian Affairs). Lao PDR, Lao People’s Democratic Republic.

Figure 2

Timeline of the intervention and research. CONNECT, Community Network Engagement for Essential Healthcare and COVID-19 responses through Trust.

Figure 3

(A) Change in the number of people receiving the first dose of COVID-19 vaccine by village. Villages 5 and 6 that implemented school-based campaigns were excluded from the main analyses as outliers. (B) Box plot showing the number of people vaccinated over 4 campaigns. Number of villages included in Visit-3, Visit-2, Visit-1 after intervention were 13, 22, 22 and 23.

Figure 4

Factors influencing the decision to be vaccinated and how these were addressed by the intervention.