Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study

"Building robust community demand for 2YL vaccination to the level achieved for Expanded Programme for Immunization infant vaccines requires time and active promotion to diffuse new practices and supporting norms among caregivers and care providers alike."

Extending the routine vaccination period beyond infancy and into the second year of life (2YL) is expected to support global vaccination targets, yet coverage rates for 2YL vaccination still lag behind infant vaccination in most settings. The most readily accessible indicator of the challenges to implementation of 2YL policies is the gap between coverage for measles-containing vaccine dose 1 (MCV1) and MCV2, which is typically the first vaccine to be introduced to the routine 2YL. This paper shares the results of a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after introducing MCV2. It was conducted as part of the Ghana Second Year of Life (2YL) project, a collaboration between the Ghana Health Service and the United States Centers for Disease Control and Prevention (CDC).

The study was conducted in the 3 regions of Ghana (Greater Accra, Volta, and Northern regions) selected for the project's planned intervention phase based on lower-than-expected MCV2 coverage. The researchers conducted 26 focus group discussions (FGDs) in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model (HBM) theory. They used Normalization Process Theory (NPT) to contextualise results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunisation schedule following 2YL introduction. NPT is a sociologically informed theory designed to understand how new material practices become embedded and ultimately integrated into the community or organisational settings.

The study found that routine immunisation for infants enjoys resilient demand, grounded in strong community norms, despite surprisingly low levels of vaccine literacy. However, in the context of 2YL vaccination, the participants of the rural FGDs, for example, perceived older children to be less vulnerable to infection and more able to withstand illness. Despite best practices like integration with the established 18-month "weighing visit", demand for 2YL vaccination is still conditional on individual awareness and competition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be "too old" to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming "too late". Thus, perceived barriers to 2YL vaccination can be summarised into themes of knowledge barriers (e.g., lack of familiarity with 2YL vaccines and schedules), unique access barriers to 2YL vaccination for caregivers with older children, concerns over side effects from the 2YL and catch-up vaccinations scheduled at the 2YL visit, and normative costs (e.g., real or anticipated criticism from community members and healthcare providers).

Among the key enablers: robust vaccine acceptance built on decades of observed safety and efficacy of infant vaccination programmes. Participants suggested better use of traditional information channels, such as chiefs and elders, to promote 2YL vaccination. Other channels of communication for vaccine information included friends, churches and mosques, and the media - both radio and television. Participants called for more information and respectful treatment from providers. For instance, in addition to information about the date of the next visit, caregivers could be provided with the name of the vaccine, the importance of the vaccine to the child, reassurance about any potential side effects, and guidance on how to manage them. Healthcare workers should be trained to treat caregivers with more respect and patience and learn to be more responsive to their questions and concerns, regardless of education level or ethnic background. Participants thought that such efforts to improve quality of care would make mothers more confident about the vaccines and increase uptake at all visits through the routine schedule. Finally, participants proposed a range of solutions to transportation challenges, particularly those facing caregivers of older children. In the short term, periodic village outreach might be needed.

Thus, from a cost-benefit perspective along the lines of the HBM framework, the findings point to weaker motivation to complete the 2YL vaccine visit compared to the better-established infant schedule. Regarding susceptibility and severity of vaccine-preventable diseases (VPDs), older children were perceived as more resistant to infection and less vulnerable to severe outcomes than infants. Regarding benefits of vaccination, there was broad consensus about the gains in child health since vaccination programmes were introduced but less clarity around added benefits of additional vaccine doses and more individual-level calculation by parents deciding whether to attend. Regarding costs of vaccination broadly defined, participants described what might be called a substantial price increase for the 18-month routine visit compared to infant visits. Cues to action embedded in the immediate social environment that provide regular reminders and that convey normative support for infant vaccination were less evident for 2YL vaccination visits, leaving caregivers to provide their own rationales and reminders to attend.

From an NPT perspective, the strong foundation of trust in infant vaccination - extending from the largest urban centres to the most remote pastoralist settings - has created favourable conditions for demand for 2YL vaccination in Ghana. Diffusion theories might predict that information interventions, specifically, will be important at the early stages of programme innovation to convince a core of early adopters to accept 2YL vaccination; the majority of later adopters are more likely to be persuaded by the behaviour of others. That is: "Building new norms and loosening the grip of the old ones will require persistent community engagement across a variety of channels, not only limited to brief radio and television announcements favoring urban audiences, to diffuse the message that complete vaccine protection is determined by the schedule, not the age of the child. As the level of social embeddedness increases, reminders and other cues-to-action begin to emerge spontaneously through horizontal networks of person-to-person interaction that create more self-sustaining demand..."

The researchers suggest that the persistence of a coverage gap between MCV1 and MCV2 in Ghana suggests the demand and access barriers identified in this study remain relevant today. Indeed, the gap has been widening since 2018. In their estimation, lessons from this analysis may also apply to vaccination platforms beyond 2YL, including the widespread disruption to childhood vaccination during the COVID-19 pandemic. Robust 2YL platforms could play a key role in responding to the volume of catch-up vaccinations required in many countries around the world.

In conclusion: "This study provides rich qualitative insights into community dynamics around 2YL assimilation 4 years after MCV2 introduction when community consensus was still forming....[C]losing the 2YL vaccination coverage gap will ultimately require modifying embedded norms among caregivers and health care providers alike."