Qualitative Insights into Reasons for Missed Opportunities for Vaccination in Kenyan Health Facilities

"Empowering caregivers and health workers with immunization information can have a positive impact on vaccine confidence and uptake..."

The World Health Organization (WHO)'s standardised methodology to assess missed opportunities for vaccination (MOV) - when eligible children have contact with the health system but are not fully vaccinated - places an emphasis on interventions to reduce MOV through a bottom-up approach to problem-solving. In that vein, to explore the underlying reasons for persistent low vaccination coverage and investigate potential interventions to improve coverage and equity, the Kenyan National Vaccines and Immunization Program (NVIP), in collaboration with partners, conducted a study of MOV in November 2016. This paper details the qualitative findings from that assessment.

Using the WHO MOV methodology, in 10 counties in Kenya, teams conducted 8 focus group discussions (FGDs) with approximately 55 health workers, 6 FDGs with about 50 caregivers of children under 24 months of age, and 35 in-depth interviews (IDIs) of key informants. The key themes that emerged from the thematic analysis (elaborated in the article through quotes recorded during the FGDs and IDIs) included:

• Perceptions of healthcare services and vaccination: Similar to their attitudes toward healthcare services, most caregivers had positive attitudes toward vaccines in general, though some reported feeling hesitant about multiple injections ("...since the introduction of a third injection [Inactivated Polio vaccine (IPV)], mothers fear that there are too many injections and thus do not bring the children on time..." - caregiver, Bungoma). There were also rumours about potential long-lasting, permanent health consequences related to vaccination and the quality of vaccines offered at health facilities.
• Vaccination checks and integration with other services: Overall, health workers and key informants acknowledged that health staff need to provide a holistic healthcare approach: "I think you need to dig deep in terms of owning that patient and finding out everything about that patient, not just why they came to the facility" (key informant, Kitui).
• Health worker staffing shortages: When health workers are overwhelmed, they are unable to take the necessary time with each patient and are only able to focus on the presenting complaint.
• Stock-outs of vaccines and vaccination-related materials: As caregivers return to their communities and report that certain supplies in the clinic are not available, other caregivers may be reluctant to return for fear of wasting their time and money. Health workers also discussed shortages of mother-and-child health (MCH) booklets, which contain the child's health history, including vaccinations: "Mothers really enjoyed [the MCH booklet]. It gave [caregivers] a sense of connection and empowerment..., and it also provided an incentive to bring the card for every health contact" (health worker, Kajiado).
• Health education: Participants in all FGDs and IDIs called for increased health education for both health workers and caregivers. Better education could help empower health workers to do their jobs better, in addition to reinforcing standard operating procedures and policies such as whether or not to open multi-dose vials. Many thought that basic health counseling at or before an appointment was effective, even for those small pockets of cultural and religious resistance and mobile populations in Kenya. Caregivers suggested that health facilities should engage the communities and involve their traditional leaders in advocating for vaccination services: "We need more discussions with the traditional leadership so they can hold meetings to inform parents on the importance of immunization and to dispel any traditional beliefs that there is no need to vaccinate" (caregiver, Trans Nzoia).

The discussion section of the paper offers some recommendations, including:

• Increase education among caregivers and provide them with the tools to advocate for vaccines. (From the caregiver perspective, health workers have been found to be a trusted source of health information, and inadequate health worker knowledge about vaccination can contribute to the under-immunisation of children.)
• Educate all health workers, including those not directly involved in administering vaccines. (Rumours about adverse events following immunisation (AEFIs) or negative health consequences, vaccine hesitancy related to multiple injections, and skepticism toward vaccine quality persist and can lead to MOV. These misconceptions can occur at multiple points of contact in the health system, so training the entire staff in a facility has the potential to alleviate the impact of such rumours.)
• Ensure that staff outside of the NVIP are properly sensitised about the childhood immunisation schedule and are able to screen and refer eligible children for vaccination.
• Improve policy and coordination at the national level, and prioritise health worker education at the county level.
• Consider alternative avenues to increasing community empowerment, such as engaging community and religious leaders.

Following field work, the teams reconvened at the national capital to brainstorm about interventions and to create an intervention plan, which the multi-partner technical working group on immunisation in Kenya went on to endorse. For example, NVIP plans to increase supportive supervision and to create an orientation package specifically designed for non-NVIP staff. Using adult learning strategies, training modules will address vaccination practices and interpersonal communication (IPC) skills. NVIP also prioritised efforts to provide counties with electronic copies of the latest versions of all documentation tools (e.g., monitoring charts, summary sheets, tally sheets, MCH booklets), and the MoH plans to disseminate updated NVIP policies and guidelines, along with updated NVIP manuals and standard operating procedures.

In conclusion, the researchers note that, although a full (quantitative and qualitative) MOV assessment was conducted in Kenya, the qualitative component "provided important data which contributed to the process of brainstorming solutions and implementing interventions to address MOV." They note that, as of 2019, 12 countries had implemented the updated WHO methodology to reduce MOV across 4 WHO regions, and "many more implementations are expected in the near future."