Contextualising Missed Opportunities for Children's Vaccination: A Theory-informed Qualitative Study in Primary Care Settings in Cape Town, South Africa

"Understanding the burden and contextual enablers of MOV is important for policy and practice as it will...enable policy makers and facility managers to consider context-appropriate interventions for strengthening immunization programmes."

Estimates (July 2020) suggest that immunisation coverage remains below the globally accepted optimal level of 90% across all routine childhood vaccine doses in South Africa. This study aimed to explore the contextual factors that may be associated with missed opportunities for vaccination (MOV) from the perspectives of healthcare providers and caregivers attending 11 primary health care (PHC) facilities in the Cape Town Metro Health District, South Africa.

The quantitative component of the study's baseline assessment indicated an average MOV prevalence of 14.1%, ranging from 9.1% to 18.9% across sub-districts in Cape Town. Nonetheless, the quantitative nature of the findings masks the underlying circumstantial and contextual factors influencing MOV. Using a theory-informed approach, the researchers therefore conducted a qualitative exploration involving 3 focus group discussion (FGD) sessions with caregivers of children aged 0-23 months and 5 in-depth interviews (IDIs) of facility staff. They used a thematic template analysis approach, integrating the theoretical domains framework (TDF) and the capability, opportunity, and motivation model of behaviour (COM-B), to code and analyse the data:

• TDF consists of the following 14 distinct, but interrelated, domains: knowledge; skills; social or professional role and identity; beliefs about capabilities; optimism; beliefs about consequence; reinforcement; intention; goals; memory, attention or decision processes; environmental context and resources; social influence; emotions and behavioural regulations.
• COM-B is a Behavior Change Wheel (BCW) approach, whereby: Capability refers to whether we have the knowledge, skills, and abilities required to engage in a particular behaviour; opportunity entails the external factors that make the execution of a particular behaviour possible; and motivation refers to the internal processes that influence our decision making and behaviours.

Findings from the FGD and IDI sessions are presented under the 3 constructs of the COM-B model, with reference to their corresponding TDF domains:

1. Capability factors comprised caregivers' knowledge, attitude and behaviour toward children's immunisation. It corresponds to TDF domains such as knowledge; skills; intention; memory; and attention or decision process. In short, many caregivers demonstrated good knowledge of the importance of vaccination, though some facility staff expressed concerns about the low level of immunisation awareness and knowledge of some caregivers. Some caregivers expressed positive attitudes toward children's immunisation; others had negative ones (e.g., due to concerns about vaccine safety).
   • Strategies for addressing issues identified under the capability construct include include facility-level efforts aimed at improving both caregiver awareness and understanding of the importance of vaccines and possible adverse events following immunisation (AEFIs). Interventions could include providing health talks and displaying posters and charts with information about immunisation in prominent areas of PHC facilities. The study found that caregivers repeatedly expressed the desire and willingness to be informed and learn about their children's immunisation, so there is an opportunity here to leverage health communication.
2. Opportunity factors included the organisation of immunization services, long waiting times, vaccine stockouts, staff shortages, and health workers' attitude, knowledge, and capability to assess children's immunisation status and needs. Perceptions of facility managers regarding immunisation services provided by their facilities were mostly positive, though there were negative concerns and dissatisfaction expressed among caregivers. One major concern commonly raised by caregivers was the unfriendly attitude of clinic staff; some caregivers said staff did not communicate effectively with them, and others complained they were often not given information on immunisation and possible AEFIs. Both caregivers and facility managers shared mostly positive views on the importance and use of road to health booklets (RtHBs) for documenting and tracking children's health status, including immunisation status.
   • Among the suggestions for addressing opportunity factors: There is a need for facility-wide service delivery policies to create an enabling environmental for all health facility staff, including immunisation and non-immunisation personnel, to correctly screen children's immunisation status and identify opportunities for administering catch-up vaccine doses at all service delivery points. Efforts are also needed to encourage caregivers to retain and bring children's RtHBs to every health service encounter to aid immunisation status checks.
3. Motivation factors included optimism and beliefs about immunisation, fear of vaccine-preventable diseases, and immunisation safety concerns. This construct corresponds to TDF domains such as beliefs about capabilities; optimism; beliefs about consequence; reinforcement; intention; goals; and behavioural regulations. Some sociocultural factors capable of influencing caregivers' decision to immunise a child when visiting a health facility emerged from the FGDs. Some caregivers mentioned the positive role of health support groups; the influence of social media was also highlighted. However, caregivers suggested that prevailing socio-cultural practices and beliefs frequently dissuade them from allowing their children to be immunised. One example is misperceptions and rumours that a child can become sick from immunisation, which have persisted despite efforts by health facility staff to educate caregivers.
   • Strategies for addressing motivation factors include those aimed at: reinforcing immunisation education; improving health workers' communication of possible adverse events to caregivers; initiating personal conversations with caregivers with particular safety concerns or misperception to allay fears and dispel myths; and using more motivated and knowledgeable caregivers as local influencers to boost other caregivers' attitude and perceptions toward immunisation at the PHC facility level.

In conclusion: "The findings offer useful practical and contextual insights for informing PHC-level quality improvement strategies for reducing MOV and ultimately improving immunization coverage at the population level."