Factors Influencing Vaccination Up-take among Nomadic Population in Four Regions of Ghana: A Qualitative Study

"Continuous public health education and sensitisation among nomads and their leaders could be one of the most important tools for addressing wrong perception[s] about vaccine safety."

In spite of the improvement in global vaccination coverage over the years, there are hard-to-reach populations such as nomads and migrants who are more vulnerable to vaccine-preventable diseases, especially in sub-Saharan Africa. This study focuses on Ghana's pastoralist nomads, who move over large areas of remote territories with their herds of livestock in search of water, pastures, better livelihoods, or safer environments. Supported by the United Nations Children's Fund (UNICEF) Ghana, this study sought to contribute to designing strategies to improve on low vaccination coverage among nomadic population in Ghana and other Sub-Saharan African countries. Findings may also inform strategies to improve cross-border vaccination programmes.

The researchers conducted 182 key informant interviews (KIIs) in 11 districts across four regions of Ghana, using a grounded theory qualitative research approach. Participants included pastoralist nomads, community leaders, community health volunteers and officers, district health management team (DHMT) members, cattle owners, staff of ministry of food and agriculture, staff of security services, butchers, and municipal/district assemblies' officials.

The KIIs revealed that vaccinations at the district and community levels were organised by the DHMT with the support of community stakeholders (assembly members, chiefs and other community leaders, such as volunteers). It emerged that the DHMT members and health workers rely on community volunteers, who are usually lay members of the community, to support in vaccinating nomadic populations. For example, one community health volunteer said: "Yes, I beat 'gong-gong' [local announcement by an individual/the official communication and information manager within a chieftaincy structure] to alert community... members to gather for vaccination at the community centre." The DHMT works in collaboration with community leaders and the security services to identify where nomads live and to help diffuse conflicts between nomads and community members. This information is useful for strategising and providing targeted vaccination services among the nomads.

Beyond community leaders, an important pathway to improve vaccination among nomadic population is the use of the nomadic leaders to support vaccination activities. A DHMT member said, "To the nomadic chiefs, yes, we know that anytime these nomads are coming in to settle, they first get permission from the chiefs; so the chiefs certainly will know their existence in the communities as well as the assemblymen."

Language was one of the main barriers to delivering vaccination services among the nomadic population. Furthermore, awareness about the disease and its severity influences vaccination among nomads. Nomads get involved in vaccinations when the disease is considered common and widespread like COVID-19. It emerged that nomads do not take other vaccinations, such as that to prevent yellow fever, seriously because they don't consider those conditions to be severe, and they do not have enough information about the conditions. Furthermore, there were some perceptions, including death attributable to vaccines, that could fuel vaccine hesitancy among the nomadic populations. Also, healthcare providers fear being attacked by pastoralist nomads and hence are hesitant to visit their settlements for vaccination. Healthcare providers' perceived use of derogatory words and discrimination against pastoralist nomads also influences their vaccination uptake.

An important approach to overcoming some of these barriers - e.g., the language barrier - to improve vaccination services among the nomadic populations is engaging "one of their own" and cattle owners. For instance, a butcher who took part in a KII explained: "...if you get some of their people who had some form of education to sit them [nomads] down and to explain to them [nomads], they will understand. If you get one of them-a female and a male-to support you, it will help them to understand. Otherwise it will be very difficult for those in the bush to come to town..." Another route to delivering service among nomadic population is strategically setting up vaccination centres at marketplaces, mosques, or the chief's palace.

It was revealed that nomads prefer male vaccinators to attend to male nomads and female vaccinators attend to female nomads during vaccination. On the other hand, some respondents who work with nomads mentioned that the personal characteristics of health workers or vaccinators such as gender and religion were not considered by nomads during vaccination, as long as the person is qualified to do the work. Though personal characteristics of vaccinators are not a barrier to vaccination among nomads, males and some ethnic speaking Muslims healthcare provides will be more acceptable to the nomads because most of the nomads understand Hausa. Also, male healthcare providers are preferable, as vaccinators may have to ride long distances to nomadic settlements

The health promotion units of the DHMTs are primarily responsible for mobilising people for health activities, including vaccinations. The DHMTs leverage the existing community structures such as community information centres, community, and volunteers to send information to the nomads. Also, vaccinators visit the residence of community members and to encourage them to go for vaccinations. Another mode of social mobilisation is leveraging the chiefs, who know and are able to locate the nomads. Emphasis was placed on nomadic chiefs who lead the nomadic communities. Finally, announcements are made at churches and mosques on impending vaccination activities as part of the mobilisation process.

Among the other recommendations to emerge from the KIIs include:
 

• Address perceptions about vaccines through continuous education and sensitisation involving nomad leadership. Like traditional societies, the leaders of the nomads exert great influence over pastoralist nomads in a particular settlement. This is largely based on trust the nomads have reposed in their leaders over a period. The health system and vaccinators could therefore take advantage of the existing nomadic leadership structures for organising pastoralist nomads for vaccinations and to improve uptake. For example, nomadic community leaders played a major role in identifying and mobilising nomads for vaccination during polio outbreak response in 2014 in Chad, which contributed to improved coverage.
• Use social and behaviour change communication (SBCC) approaches to improve the sending of information on vaccination activities to the nomadic population, including the use of local radio stations and community information centres. These approaches are already used but could be improved, using Hausa and Mosi languages.
• Engage school pupils to transmit information on vaccination activities. Specifically, information could pass from teachers to their pupils and to parents in various homes.
• Provide capacity building for health workers in the area of customer care - i.e., treat all patients and clients without discrimination.
• Train some of the nomads to do the vaccination. 
• Do joint vaccination among nomads and their animals. Veterinary officers vaccinate the animals of nomads from time to time. Consequently, the health workers could partner with the veterinary officers to do a joint vaccination.
• Schedule vaccination activities for specific days such as Fridays, when most community members, including nomads, come to town. Chiefs and Aassemblymen could also liaise with butchers to inform nomads about vaccination when they come to town on Fridays.

In conclusion: "Leveraging existing partnership between the health services and community leaders, information centers, volunteers and butchers to send health information to pastoralist nomads [can] influence vaccination uptake....Strengthening Ghana Health Service collaboration with leaders of pastoralist nomads could build trust, create awareness and overcome language barrier between healthcare providers and pastoralist nomads."

Full list of authors, with institutional affiliations: Samuel Afari-Asiedu, Ghana Health Service; Lawrence Gyabaa Febir, Ghana Health Service; Charlotte Tawiah, Ghana Health Service; Semeeh Omoleke, United Nations Children's Fund (UNICEF) consultant; Porbilla Ofosu-Apea, UNICEF Ghana; Felix Osei-Sarpong, UNICEF Ghana; Antoine Marie Cyrille Ziao, UNICEF Ghana; Charles Kyei, Ghana Health Service; Edward Anane Apraku, Ghana Health Service; Augustine Antwi, Ghana Health Service; Chrysantus Kubio, Regional Health Directorate; Anthony Adofo Ofosu, Ghana Health Service; Peter Gyamfi Kwarteng, UNICEF Ghana; Mrunal Shetye, UNICEF Ghana; Kwaku Poku Asante, Ghana Health Service