Provider Perspectives on Demand Creation for Maternal Vaccines in Kenya

Expansion of maternal immunisation coverage requires broad acceptance by both pregnant women and their healthcare providers (HCPs). Field and clinic strategies are being employed to increase vaccine access, and behavioural-communication research findings have been used to inform vaccine messaging strategies. In particular, one approach to maintaining high coverage rates involves enabling providers to use effective messaging during patient interactions. The purpose of this study is to describe issues surrounding vaccine acceptance and demand creation from a provider perspective in order to inform future efforts to introduce new maternal vaccines in low- and middle-income countries.

The analysis draws on data from a large, in-depth study of determinants of maternal vaccine acceptance in Kenya. The final sample of 111 HCPs included nurses (n=97) and clinical officers (n=14). Six major themes emerged from the semi-structured interviews, which were conducted between January and August 2017 in 4 geographically diverse locations (Marsabit, Nairobi, Mombasa, and Siaya). These themes are illustrated in the article with quotations from providers. In brief:

1. The centrality of the patient-provider relationship in vaccine promotion: Providers expressed that they were pregnant women's primary source of health information, and that it was therefore their duty to educate pregnant women about maternal vaccines. Many providers expressed confidence that patients would accept their instructions without question, especially in rural facilities where patients are felt to have more limited knowledge. However, some acknowledged that expectations of total patient deference are changing as women become more comfortable initiating requests for information. This openness to two-way exchange was more commonly expressed among urban providers.
2. Cultural, religious, and social factors influencing vaccine acceptance among patients: Some providers highlighted the limited agency of pregnant women regarding their own medical decision-making. Providers cited community and religious institutions as both barriers and facilitators of vaccine acceptance among their patients. For example, one Nairobi provider said, "During the polio campaigns, the Akorino rejected it in Eastern Kenya because their religion does not allow them to take medication." On the other hand, a provider in Marsabit suggested that community meetings would be an ideal venue to reach those who might otherwise not come for antenatal classes (ANC).
3. Resources needed for improved vaccine delivery: Providers almost universally cited time constraints and provider overwork as barriers to providing adequate patient education about vaccines. Educational materials for patients were often described as absent or inadequate, and some providers suggested that patient brochures needed to be translated into local languages, as women at their clinics did not read English or Swahili. Providers expressed a desire for continuing professional education, particularly on newer vaccines. One provider linked professional education to patient acceptance.
4. Differences in provider knowledge about maternal vaccines: While the majority of providers are comfortable in their knowledge of vaccines currently in the national schedule and available at their facilities, few are knowledgeable about vaccines not offered at their facilities, or about upcoming vaccines.
5. Favourable attitudes toward maternal vaccines: The majority of providers expressed the view that tetanus toxoid was beneficial to pregnant women and infants, and were open to new vaccines being introduced. Providers were less comfortable endorsing vaccines with which they were not personally familiar, especially those at public facilities.
6. Patient access issues: Distance to health facilities and lack of transportation were among the major access issues perceived by providers to hinder maternal vaccine coverage.

In reflecting on the findings, the researchers note that giving patients printed, evidence-based materials that could be taken home could mitigate some provider overwork issues. Political decentralisation provides opportunities and challenges for county-level government to publish regionally tailored resources for patients and providers; multimedia and local language options could improve accessibility and impact, especially among women with limited English and Swahili literacy. It may also be beneficial to incorporate communication strategies into ongoing professional education efforts to empower providers to use their limited time with patients more effectively. Such professional updates need to be proactive so that providers are educated ahead of public vaccination campaigns and are prepared to deal with patient questions and concerns.

Finally, providers highlighted the need to engage religious and community leaders as allies in demand creation and promotion of new vaccines. As the decline in polio vaccine coverage in northern Nigeria demonstrates, failure to elicit buy-in from influential religious groups can result in large-scale failure to promote even familiar vaccines. Providers suggested that religious groups could be engaged as allies to reach women who might otherwise not receive health messaging. The researchers suggest that future efforts to support maternal vaccination should also include male decision-makers, including husbands, fathers, and brothers.