Attitudes towards new tuberculosis vaccines among adults, adolescents and their caregivers in southern Mozambique, 2024

A 2024 mixed-methods study in southern Mozambique reveals that 77% of adults and adolescents are willing to receive a new tuberculosis vaccine, with adolescents showing significantly higher willingness than adults and overall uptake likely to be high if the vaccine is endorsed by trusted authorities.

The Gist

Imagine tuberculosis (TB) as a stubborn, invisible fog that has been hanging over many communities for decades. For a long time, we've only had one tool to fight it: a vaccine for babies (like a tiny umbrella for infants). But now, scientists are developing a new, powerful shield (a vaccine) specifically for teenagers and adults to clear that fog.

However, a shield is only useful if people are willing to hold it up. This study is like a community town hall meeting held in southern Mozambique in 2024, where researchers asked a simple question: "If we bring this new shield to your village, will you use it?"

Here is the story of what they found, told in everyday terms:

1. The Big Picture: Most People Are Ready

Out of the people they asked, 77% said "Yes, absolutely!"
Think of it like a concert where 3 out of 4 people are already holding up their tickets, ready to get in. This is great news because it means the "demand" for the vaccine is high. The community isn't saying, "No thanks, we don't need this." They are saying, "We're ready."

2. The Teenagers vs. The Grown-Ups

There was a funny twist in the crowd. Teenagers were much more excited about the new vaccine than the adults were.

• The Teenagers: They were like eager students at the front of the class, raising their hands immediately. About 88% of them said yes.
• The Adults: They were more like cautious parents checking the ingredients list before buying a snack. Only about 74% said yes.
• Why? The study found that adults, especially men, were a bit more skeptical. They wanted to know exactly how the vaccine works before they trusted it. It's not that they didn't want to be healthy; they just wanted to understand the "how" and "why" first.

3. The "Knowledge is Power" Rule

The study discovered a golden rule: The more you know about TB, the more likely you are to want the vaccine.

• Imagine TB as a scary monster. If you think the monster is a myth, you don't bother buying a sword. But if you know the monster is real, you know it can kill you, and you've seen it hurt your neighbors, you are much more likely to grab that sword (the vaccine) immediately.
• People who had TB themselves, or knew someone who did, were the most eager to get vaccinated. They understood the danger better than anyone.

4. Who Do People Trust? (The "Who's Who" of Trust)

When people were asked, "Who should tell you it's safe to take this vaccine?" they didn't point to TikTok, Instagram, or random news sites.

• The Trusted Voices: They pointed to their doctors, the government health officials, and local community leaders (like the village head or a respected elder).
• The Untrusted Voices: Social media was seen as a noisy, unreliable rumor mill.
• The Lesson: If you want people to get vaccinated, you don't need a viral internet meme. You need a trusted doctor or a local leader to say, "This is safe, and it works."

5. The "Maybe" Group

A small group of people said, "Maybe." They weren't saying "No," but they were hesitant.

• The Reason: They felt like they were being asked to jump off a cliff without knowing if there was a net below. They needed more information.
• The Fix: The study suggests that if you explain clearly how the vaccine works and why it's needed, most of these "Maybe" people will turn into "Yes" people.

6. The Surprising Twist

One finding was a bit of a curveball. People who had trouble getting vaccines in the past (maybe they missed a bus, or the clinic was closed) were actually more willing to take this new one.

• The Analogy: It's like someone who missed a bus for years finally seeing a new bus stop right outside their house. They are so relieved and motivated to catch this one that they are even more eager than those who never had trouble getting on a bus before.

The Bottom Line

This study is like a roadmap for the future. It tells us that in southern Mozambique, the path to vaccinating adults and teens is wide open.

• The Good News: Most people want the vaccine.
• The Strategy: To get everyone on board, we need to:
  1. Give teenagers the vaccine (they are ready!).
  2. Give adults more clear, simple information so they feel confident.
  3. Let doctors and local leaders do the talking, not social media.
  4. Remind everyone that knowing about TB makes you want to protect yourself.

If we follow this map, this new vaccine could be a game-changer, clearing the "fog" of TB and keeping communities safe.

Technical Summary

1. Problem Statement

Despite the high global burden of tuberculosis (TB), progress in reducing morbidity and mortality has been slow, exacerbated by the COVID-19 pandemic. While new TB vaccines are under development for adults and adolescents to transform prevention programs, their efficacy depends on widespread population coverage. However, global vaccine confidence has eroded, and attitudes toward new vaccines vary significantly by setting. There is a critical lack of data regarding the demand for and acceptance of novel TB vaccines specifically among adults and adolescents in high-burden settings, particularly in sub-Saharan Africa where HIV and TB co-infection is prevalent. Understanding these attitudes is essential for planning communication strategies and maximizing uptake once a vaccine is licensed.

2. Methodology

The study employed a convergent mixed-methods design, collecting quantitative and qualitative data concurrently with equal emphasis.

• Study Setting & Population: Conducted in the Manhiça district of southern Mozambique (a high HIV/TB burden area) from February to July 2024.
  • Participants: Adults (≥18 years), adolescents (9–17 years), and caregivers of adolescents.
  • Recruitment: Community-based household sampling via a demographic surveillance system and recruitment from the TB outpatient clinic at Manhiça District Hospital.
• Data Collection:
  • Quantitative: A cross-sectional survey ($N=241$; 151 adults, 41 adolescents, 49 caregivers) assessing demographics, vaccination history, TB knowledge, and willingness to receive a new TB vaccine. Survey tools were based on the Behavioral and Social Drivers (BeSD) framework.
  • Qualitative: In-depth interviews ($N=23$) with a purposive sample representing diverse survey responses (willing/unwilling, TB patients/non-patients). Interviews explored perceptions, motivations, and barriers.
• Analysis:
  • Quantitative: Univariable and multivariable logistic regression were used to identify determinants of willingness (classified as "Yes" vs. "No/Unsure").
  • Qualitative: Thematic analysis using open coding and the BeSD framework domains (Thinking/Feeling, Social Processes, Motivation, Practical Issues).
  • Integration: A joint display was used to triangulate quantitative and qualitative findings.

3. Key Contributions

• First Study of its Kind: This is the first study to explore community perceptions of new TB vaccines specifically targeting adults and adolescents in a high-burden setting.
• Mixed-Methods Integration: It uniquely combines statistical associations with deep qualitative insights to explain why certain demographic groups are more or less willing to vaccinate.
• Demographic Specificity: It highlights significant disparities in vaccine acceptance between adolescents and adults, and between genders, which are crucial for targeted rollout strategies.
• Framework Application: The study applies the BeSD framework to TB vaccine hesitancy, providing a structured understanding of the drivers of acceptance in this context.

4. Key Results

Quantitative Findings:

• Overall Willingness: 77% (148/192) of adults and adolescents expressed willingness to receive a new TB vaccine.
• Age Disparity: Adolescents were significantly more willing to be vaccinated than adults. In multivariable analysis, adolescents had 5.6 times higher odds of willingness compared to adults (Adjusted OR: 5.6, 95% CI: 1.7–17.7).
• Gender Differences: Adult men were less willing than women (20% of men said "No" vs. 4% of women). Conversely, adult women expressed more uncertainty ("Maybe") than men.
• Knowledge & Experience:
  • Higher levels of TB knowledge were associated with increased willingness (though the adjusted OR was not statistically significant at $p<0.05$, the trend was strong: OR 2.6).
  • Personal experience with TB (having a friend/family member with the disease) was associated with higher willingness.
• Access History: Counter-intuitively, participants who reported previous issues accessing vaccines were more willing to receive a new TB vaccine (Adjusted OR: 3.3).

Qualitative Findings:

• Drivers of Hesitancy: Hesitancy among adults was primarily driven by a lack of information regarding how the vaccine works and why it is needed, especially given the existence of the infant BCG vaccine.
• Trusted Sources: Healthcare providers, government agencies, and community leaders were identified as the most trusted sources of information. Social media was largely distrusted.
• Motivation: Participants emphasized the importance of vaccine effectiveness in preventing TB and protecting vulnerable family members (especially children).
• Practical Preferences: Vaccination sites like schools, clinics, and hospitals were preferred due to existing trust and familiarity with these health interventions.

Integration of Findings:
The qualitative data explained the quantitative trends: adults' lower willingness was linked to information gaps, while adolescents' high willingness reflected a general openness to new health interventions. The finding that those with past access issues were more willing was interpreted as a sign of high motivation despite logistical barriers, rather than a lack of trust in the system.

5. Significance and Implications

• High Potential Uptake: The 77% willingness suggests moderate-to-high potential uptake for a new TB vaccine in this setting, which is higher than current uptake for TB Preventive Therapy (TPT) but lower than historical malaria vaccine acceptance in some contexts.
• Targeted Communication:
  • Adolescents: Likely to be early adopters; strategies should leverage their openness.
  • Adult Men: A critical target group due to higher TB burden and transmission risk; they require specific outreach to address skepticism.
  • Adult Women: Need clear, detailed information to resolve uncertainty.
• Communication Strategy: Campaigns should prioritize trusted messengers (health workers, community leaders) and avoid reliance on social media. Messaging should focus on the mechanism of action, efficacy, and the protection of family members.
• Policy Planning: These findings provide a baseline for modeling vaccine introduction and designing communication campaigns for when a new TB vaccine is licensed for adults and adolescents in Mozambique and similar high-burden settings.

Limitations: The study was small ($N=241$), non-representative of the entire nation (over-represented women and TB patients), and faced challenges in eliciting deep responses from adolescent interviewees. Willingness does not guarantee actual uptake.