Vaccination Information, Motivations, and Barriers in the Context of Meningococcal Serogroup A Conjugate Vaccine Introduction: A Qualitative Assessment among Caregivers in Burkina Faso, 2018

"The findings point to the importance of strong communication efforts by healthcare workers and other trusted sources of information regarding the timing and benefits of the new vaccines, especially after 11 months of age. Improving MACV and MCV2 coverage may require increased investments in community engagement..."

An interplay of supply- and demand-side factors impact access to and acceptance of childhood vaccines in low- and middle-income countries (LMICs). Previous qualitative assessments in Burkina Faso found that behavioural drivers of vaccination include parental understanding of childhood diseases, knowledge of the immunisation schedule, logistical and practical constraints, and past experiences with immunisation services. In March 2017, Burkina Faso introduced meningococcal serogroup A conjugate vaccine (MACV) into the Expanded Programme on Immunization (EPI). MACV is administered to children aged 15-18 months, concomitantly with the second dose of measles-containing vaccine (MCV2). One year after MACV introduction, the researchers assessed the sources and content of immunisation information available to caregivers and explored motivations and barriers that influence their decision to seek MACV for their children.

The assessment comprised 24 focus group discussions (FGDs) with caregivers of children eligible for MACV and MCV2. The FGDs were conducted between February and March 2018 in four districts.

In summary:

• Caregivers reported receiving various messages reminding them to return to the health centre for the 15-18-month visit, along with messages promoting the protective benefits of MACV and MCV2 and the overall health benefits of childhood vaccination.
• Caregivers described receiving information about MACV from multiple and diverse sources, including healthcare workers (most commonly cited), community health workers, mass media programmes (e.g., television or radio), other caregivers in their community, cultural and religious leaders, and town criers. Some caregivers mentioned their desire for in-person discussions on vaccination with healthcare workers and community health workers.
• The researchers identified caregivers in both the vaccinated and unvaccinated groups who said they had not received information from any source regarding the 15-18-month visit for MACV. Their lack of awareness was often linked to not being informed at healthcare centres to return for vaccination when the child is 15 months old, inadequate community engagement, and difficulty understanding the vaccination information provided (e.g., print materials that were beyond the reach of illiterate caregivers).
• Caregivers' motivations to seek MACV for their children were mainly driven by awareness of the childhood vaccination schedule, engagement with trusted messengers and other caregivers in the community, and the perceived protective benefits of MACV. When asked about future intention to vaccinate, caregivers with unvaccinated children cited that knowing when to attend vaccination visits and knowing that the vaccines are free would motivate them to vaccinate their children in the future.
• Healthcare workers were most commonly viewed as trusted messengers by participants across all regions and, in numerous instances, caregivers cited healthcare workers' recommendations as the driving reason for vaccinating their children. FGDs revealed that caregivers considered other women in the community, including elder village women, as key trusted resource persons to help build trust in MACV.
• General barriers to MACV and MCV2 uptake included the unavailability of vaccines, withholding of vaccines by immunisation personnel, knowledge gaps (e.g., immunisation information being perceived as too technical), practical constraints, sociocultural influences (e.g., needing approval from husbands), and misinformation about vaccination. Caregivers of unvaccinated children also listed past negative experiences with healthcare workers, such as rude and condescending behaviour toward women who have missed visits.

Findings from the FGDs were consistent with the Health Belief Model (HBM), in which perceived threat (susceptibility and severity) of a disease is an important driver of adopting protective behaviours, including vaccination. The HBM's fit within this context is reflective of Burkina Faso's being situated in the meningitis belt of sub-Saharan Africa, which experiences high endemic rates of meningitis, annual seasonal outbreaks, and "explosive" epidemics occurring every 5-10 years.

The barriers captured in this assessment may help explain why meaningful coverage improvements have not been observed following vaccine introductions in Burkina Faso and other LMICs. A major barrier cited by caregivers was the need to return multiple times to healthcare centres because healthcare workers often withheld the vaccine until there were enough eligible children present. This circumstance may be explained by a reluctance of healthcare workers to open multidose vaccine vials to avoid wastage, a behaviour documented both in Burkina Faso and elsewhere, contrary to World Health Organization (WHO) vaccine management guidelines.

Moreover, this study found misinformation among caregivers regarding the need for MCV2. Some caregivers expressed that since the vaccines given at 9 and 15 months are the same, there was no need for the 15-month visit. This finding reflects gaps in knowledge about measles vaccine being a 2-dose series, coupled with poor awareness of MACV being offered at the 15-18-month visit despite comprehension of the risk and severity of meningitis. These findings emphasise the need to provide reminders and simple-to-understand information about the vaccination schedule overall, especially for vaccines offered in the second year of life that may have lower awareness among caregivers.

The researchers suggest that the findings shed light on programmatic and policy considerations when introducing MACV into the EPI in other countries in the meningitis belt. Countries introducing other new vaccines recommended in the second year of life may face similar challenges. For example, countries choosing to introduce typhoid conjugate vaccine (TCV) in the second year of life are most likely to do so at the 15-18-month visit and may face the barriers seen in this study.

In conclusion: "MACV and MCV2 uptake may be enhanced by addressing vaccination barriers and effectively communicating vaccination information and benefits through trusted messengers such as healthcare workers and other caregivers in the community. Educating healthcare workers to avoid withholding vaccines, likely due to fear of wastage, may help reduce missed opportunities for vaccination....New vaccine introductions should be accompanied by community assessments to understand the dynamics around information (and misinformation), motivations, and barriers related to uptake of the new vaccine."