Locating Vaccine Uptake and Public Participation in Ukraine: An Exploratory Qualitative Study on Attitudes and Barriers to Early Childhood Vaccination

"This study suggests that the decision to vaccinate is influenced by the social environment and interventions should consider this side of vaccine hesitancy alongside more basic measures such as information provision."

A growing body of literature highlights the need to consider context, group influences, and perceptions of particular vaccines to first understand what contributes to low vaccine uptake and then to address these factors using community-based principles. Conducted in Ukraine, a country that experienced a wave of measles cases in 2018 and a war that began in 2022, this study explores how vaccines are perceived and how local stakeholders envision solutions to the problem of low vaccine uptake. The focus is on nationally recognised vulnerable groups, including low-income families and Roma communities. In this way, "by identifying context-specific vulnerabilities with rich data on real-world experiences of those most affected by a particular disease, local actors can be engaged in responding to vulnerabilities."

From May-July 2021, the researchers carried out: (i) 25 in-depth semi-structured interviews with 15 parents of children under 6 years of age, along with 10 stakeholders and experts, and (ii) a stakeholder dialogue meeting with 13 participants to discuss interview results and propose policy recommendations and other solutions.  

With regard to structural and health system constraints, Roma communities or low-income households may face the barriers of geographic distance from healthcare facilities or of having to show identifying documents to access health care. Examples of other factors that impede their access to vaccination are: lack of community resources, lack of funds for proper nutrition and medicine, and low levels of education. Roma parents worried that their children would not be vaccinated with the same vaccines as children in the general population. In addition, this group had a low awareness of vaccine-preventable diseases, with the exception of tuberculosis. Moreover, some participants indicated they had strained relationships with their general practitioners or other healthcare providers. Two women expressed confusion about navigating the health system and a lack of readily available and comprehensible information from doctors.

A second, complementary domain is the varying perceptions of and sources of information surrounding childhood vaccination. Some groups might face structural barriers to accessing reliable information or health facilities and resort to other sources. Respondents indicated that these sources could include family members or other people in their communities, religious organisations, or the internet. The strength of evidence-based information from official sources is at times in opposition with anecdotal knowledge. Thus, the magnitude and diversity of opinions on vaccines was seen to be barrier for some. Most of the parent respondents indicated they were not opposed to vaccination. However, fear of negative vaccine side effects proved to be one of the main drivers of hesitation. Occurrence of these side effects was believed to depend on the country of vaccine production, and there is prejudice towards vaccines made in India or other Asian countries. Mistrust of the health system and lack of access to reliable information preceded many doubts parents expressed surrounding vaccines.

After hearing about the results of the interviews (presented above), the stakeholders discussed and recommended 3 main areas improvement based on the presentation of interview results:

1. Improved information provision around vaccines: Participants mentioned that organisations such as the Public Health Center of the Ministry of Health of Ukraine can use more adapted insights on contextual factors contributing to vaccine hesitancy in order to better their public messaging on vaccines. Access to trustworthy information should be increased, especially for those in geographically remote locations.
2. Incorporation of these and similar research findings into future trainings for healthcare practitioners: For example, the group indicated that health practitioners should increase their skills and knowledge of vaccine uptake in vulnerable groups, including: knowledge about the problems that certain groups face and adapted working methods for approaching these groups, as well as use of standardised materials, such as the official immunisation schedule.
3. Improved services for Roma populations: Participants argued that more could be done to strengthen civil society organisations that work with Roma communities. In general, community engagement should be a sustained and institutionalised endeavour that encourages access to and use of health services, including vaccines. Some concrete actions that can be taken include translating information into local languages and removing the requirement to show identifying documents at health facilities.

"What is immediately clear from the results of this study is that vaccine uptake is a multi-factor phenomenon, and one that is especially dependent on structural aspects like access to trustworthy healthcare services. What is termed vaccine hesitancy, then, may be better framed in this context to consider the more structural ways that contribute to low vaccine uptake, including lack of access....Returning to the concept of vulnerability, we see that this process of having to search for answers outside the health system is a relational one, where factors such as ethnic identity, income level, or geographic location contribute to a better or worse relationship to reliable and responsive health services."

In conclusion: "Vulnerability is a concept that can help frame our understanding of what influences vaccine uptake, moving beyond strictly biomedical or behavioural notions of the issue to include all of the relational aspects of information and access to vaccines. We can also say that, compared to other approaches, engaging with communities and encouraging participation may result in more novel or applicable solutions, as was seen here in the stakeholder engagement process. Finally, qualitative methods and the use of social science concepts can be vital in understanding vaccine uptake (and vaccine hesitancy) within certain communities and producing and solutions. Concepts that move beyond individual behaviour change theories and consider some more structural and social aspects may be useful for approaching vaccine hesitancy in Ukraine and in other contexts."