“Better to die trying”: Vaccine perceptions and COVID-19 experiences in rural Namibian pastoralists

Substantial research indicates that local explanatory models of disease shape heath behaviors. However, less is known regarding how cultural models of disease influence interpretations of vaccines. Vaccination decisions are based around a plethora of social and cultural factors, including beliefs about disease, cultural-historical experiences with healthcare, and recent vaccination experiences. To understand how local interpretations of vaccination influence vaccination-decision making, we explore cultural models of health, vaccine norms, and COVID-19 beliefs and experiences in Himba and Herero pastoralists of the Kunene region of northern Namibia. Mixed sex focus groups were conducted in July and August of 2024 in communities across a rural and peri-urban gradient. Discussion prompts were designed to elicit dialogue on vaccination beliefs, norms, and experiences, as well as their recent experience with COVID-19. Results from these focus groups indicate that there was substantial confusion differentiating vaccinations from other types of injections. For childhood vaccines, immunization is normative and expected. Women were the primary decision-makers for childhood immunization, reflecting the matrilineal bias of Himba and Herero kinship. For adults, while local leaders had some influence interfacing with public health outreach, the decision to get vaccinated was largely a personal one. Beliefs about COVID-19 were interpreted through pre-existing cultural models of illness, and beliefs about the origins of COVID-19 reflected mistrust in international actors. Fears about COVID-19 vaccines were common, particularly concerns about vaccine safety. However, fears of the illness typically overrode fears of the vaccine, and most report receiving the vaccine despite these worries. These results highlight the importance of extending research beyond a knowledge, attitude, practice framework to incorporate local explanatory models and cultural-historical experiences in understanding vaccine-decision making. These features are particularly important in more traditional, rural, and marginalized populations where medical mistrust is common and local explanatory models of disease drive healthcare decision-making.