"Fear of the Unknown": Health, Disability, and Stakeholder Perspectives on the Behavioral and Social Drivers of Vaccination in Children with Disability in Fiji

"The findings from this study can inform strategic actions to overcome barriers to vaccination for children with disability, including strengthening existing vaccination programmes and promoting greater equity in vaccination for children with disability in Fiji."

Over 90% of children with disability worldwide live in low- and middle-income countries (LMICs). Vaccinating these children is a key priority for equity, because children with disability often face multiple barriers to accessing vaccination. It is hypothesised that children with disability make up a significant portion of the unreached and unvaccinated population in Fiji. This study aimed to understand the social and behavioural drivers (BeSD) of vaccine uptake among children with disability in Fiji, from the perspectives of health, disability, and community stakeholders.

To inform the present study, the researchers conducted a cross-sectional survey to examine vaccination rates in children with disability in peri-urban and urban areas of the Suva–Nausori corridor (the same location as the present study). They found that only 55% of children with disability were vaccinated against basic antigens, and 23.1% reported difficulties accessing vaccinations.

A 12-member stakeholder group was actively engaged and involved throughout all stages of the present study. The group included local and international disability and health service providers (study partners), the Fiji Ministry of Health and Medical Services (MHMS), academics, and community and faith leaders. The stakeholder group identified focus groups as the preferred method for data collection, as participants were anticipated to feel more comfortable sharing their opinions in a group setting, and the exchange of ideas could yield a deeper, richer understanding of sensitive and potentially taboo topics.

Five qualitative focus groups were conducted with 22 stakeholders, including healthcare workers, disability service providers and advocates, and community and faith leaders (female n = 17, 77%). Data were collected and analysed using reflexive thematic analysis and applied the World Health Organization (WHO's) BeSD of Vaccination framework (see Related Summaries, below). This framework offered a guide to examine not only individual beliefs and behaviours but also social, cultural, and systemic drivers that can impact vaccine acceptance, access, and uptake. This framework is thought to be well suited for informing strategies to improve equitable vaccine uptake in contexts with diverse social and healthcare challenges.

Numerous drivers were reported to impact vaccination for children with disability. These included:
 

• Thinking and feeling: Participants reported a lack of reliable information about vaccine benefits and safety for children with disability. Safety concerns may be exacerbated for families of children with disability due to pervasive myths incorrectly linking vaccinations with childhood disability. Participants reported that when information about vaccines was provided to parents, it was often incomplete in that it focused solely on the benefits and neglecting potential side effects. One participant called for "information to suit all types of impairment", including "in pictorial, or in simple terminology". Participants explained that advocating to parents about the importance of vaccination was essential to build bridges to vaccine acceptability.
• Social processes: Participants reported that children with disability and their parents experienced stigma and discrimination when accessing healthcare facilities and that this reduced engagement with vaccination programmes. They articulated the need for a range of tailored initiatives to build awareness and understanding among parents of children with disability about the need for vaccination. They explained that engaging parents of children with disability demanded a thoughtful approach including collaboration with local leaders. The findings also emphasise the importance of disability and health services working together to improve vaccine uptake for children with disability. Participants suggested that disability services were often a trusted source of information and could be instrumental in encouraging vaccination.
• Motivation: Participants explained that parents, particularly mothers, lacked support and faced structural barriers in caring for their children with disability, preventing engagement with vaccination. In addition, religious beliefs complicated vaccination engagement. Participants explained that vaccination "all depends on the family agreeing or disagreeing" and that vaccine hesitancy was most common among "faith-based" parents.
• Practical issues: Long waiting times and lack of suitable waiting areas for children with disability, financial and time barriers, and lack of healthcare worker knowledge and confidence in providing vaccines to children with disability all impacted patient-provider trust. Several participants reported instances of healthcare workers administering vaccinations to children with disability without first obtaining parental consent or explaining the nature of the vaccinations. These experiences made parents hesitant to visit medical centres.

Thus, the findings demonstrate the numerous and complex drivers and barriers to vaccination faced by children with disability in Fiji, highlighting the urgent need to enhance the inclusiveness of vaccination health services and communication for this population. Suggestions include:
 

• Promote collaboration between disability and health services to optimise and strengthen immunisation referral pathways, capitalising on the effectiveness of local interpersonal communication to support decision-making.
• Develop tailored public education and awareness activities for children with disability and coordinated advertising campaigns across various media technologies.
• Provide education and training for healthcare workers to build capacity in working with children with disability and their families. Training should encompass strategies to address disability stigma, contraindications, if any, including vaccine safety, and clear protocols for communication and consent tailored to children with disability and their families. Previous research showed that healthcare workers can communicate the evidence of strong scientific agreement supporting vaccines, debunk vaccine myths with humour, and warn people about the potential for misinformation. In addition, training should equip healthcare workers with practical skills for adapting vaccination approaches to support children with varying mobility and communication needs.
• Improve accessibility of vaccination clinics, and implement outreach programmes, house-to-house vaccinations, and after-hours vaccination clinics.

In conclusion: "By understanding and addressing the behavioral and social factors contributing to the low vaccination rates of children with disability, targeted public health interventions and vaccination campaigns can be developed. These efforts will empower families to vaccinate their children with disability and improve the knowledge and confidence of health workers to administer vaccines to this population."

Full list of authors, with institutional affiliations: Rosalie Power, Western Sydney University; Unise Vakaloloma, Fiji National University; Israt Jahan, Central Queensland University; Sureni Perera, Frank Hilton Organization; Ilisapeci Tuibeqa, Ministry of Health and Medical Services, Suva, Fiji; Rachel Devi, Ministry of Health and Medical Services, Suva, Fiji; Litiana Volavola, Ministry of Health and Medical Services, Suva, Fiji; William May, Fiji National University; Donald Wilson, Fiji National University; Lanieta Tuimabu, Fiji Disabled People's Federation; Gulam Khandaker, Central Queensland Hospital and Health Service; and Meru Sheel, The University of Sydney, and The University of Health - on behalf of Australian Immunisation and Disability Investigators