ArticleBulletin of the World Health Organization2021
Insights into vaccine hesitancy from systems thinking, Rwanda.
Article in Bulletin of the World Health Organization, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 14 papers, 1 of them a synthesis that pooled it.
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Who cites it
14 citing papers in PubMed, 1 synthesis or guideline pooled it, 21 citations in OpenAlex.
- The impact of COVID-19 on general vaccine acceptance in low- and middle-income countries: a systematic review.Frontiers in public health · 2026Pooled it
- Barriers to uptake of vaccination among communities in the city of Kigali, 2025.BMC public health · 2026Article
- A systems approach to understanding mechanisms underlying immunisation barriers: a participatory design study in Tanzania.BMJ global health · 2026Article
- Article
- Review
- Hesitancy towards COVID-19 booster vaccine among healthcare workers in Bangladesh.BMC health services research · 2025Article
- The acceptance of COVID-19 vaccines in Rwanda: a cross-sectional study.BMC public health · 2024Article
- Conflicting and complementary notions of responsibility in caregiver's and health care workers' vaccination narratives in the Philippines.Journal of global health · 2024Article
- How Can Authorities Support Distributed Improvisation During Major Crises? A Study of Decision Bottlenecks Arising During Local COVID-19 Vaccine Roll-Out.Journal of cognitive engineering and decision making · 2023Article
- Understanding Drivers of Vaccine Hesitancy During the COVID-19 Pandemic Among Older Adults in Jiangsu Province, China: Cross-sectional Survey.JMIR formative research · 2023Article
- Models of determinants of COVID-19 vaccine hesitancy in non-pregnant and pregnant population: Review of current literature".Human vaccines & immunotherapeutics · 2022Review
- Systems Science and Evidence-Informed Deliberation to Mitigate Dilemmas in Situations of Dual Agency at the Hospital Level Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations".International journal of health policy and management · 2022Article
- Acceptance of COVID-19 booster vaccination based on the protection motivation theory: A cross-sectional study in China.Journal of medical virology · 2022Article
- Harnessing the power of behavioural science to improve health.Bulletin of the World Health Organization · 2021Article
Corrections and comments
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Authors and funding
8 authors at 2 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveTo investigate vaccine hesitancy leading to underimmunization and a measles outbreak in Rwanda and to develop a conceptual, community-level model of behavioural factors.
methodsLocal immunization systems in two Rwandan communities (one recently experienced a measles outbreak) were explored using systems thinking, human-centred design and behavioural frameworks. Data were collected between 2018 and 2020 from: discussions with 11 vaccination service providers (i.e. hospital and health centre staff); interviews with 161 children's caregivers at health centres; and nine validation interviews with health centre staff. Factors influencing vaccine hesitancy were categorized using the 3Cs framework: confidence, complacency and convenience. A conceptual model of vaccine hesitancy mechanisms with feedback loops was developed.
findingsA comparison of service providers' and caregivers' perspectives in both rural and peri-urban settings showed that similar factors strengthened vaccine uptake: (i) high trust in vaccines and service providers based on personal relationships with health centre staff; (ii) the connecting role of community health workers; and (iii) a strong sense of community. Factors identified as increasing vaccine hesitancy (e.g. service accessibility and inadequate follow-up) differed between service providers and caregivers and between settings. The conceptual model could be used to explain drivers of the recent measles outbreak and to guide interventions designed to increase vaccine uptake.
conclusionThe application of behavioural frameworks and systems thinking revealed vaccine hesitancy mechanisms in Rwandan communities that demonstrate the interrelationship between immunization services and caregivers' vaccination behaviour. Confidence-building social structures and context-dependent challenges that affect vaccine uptake were also identified.
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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.