A Systematic Review of Factors That Influence Parents' Views and Practices around Routine Childhood Vaccination in Africa: A Qualitative Evidence Synthesis

"While there is increasing attention being paid to the demand side of vaccination, we currently have limited understanding of the factors that influences caregivers' views and practices regarding routine immunization among children in Africa....Qualitative research can contribute to the understanding of these factors, as it is a well-suited tool to study people's beliefs, behaviours, and decision making. It can also help inform policy and practice..."

Vaccine hesitancy, a motivational state of being conflicted about or opposed to vaccination, is influenced by factors such as complacency, confidence, and convenience. A Cochrane review that explored the factors that influence caregivers' views and practices around routine childhood vaccines included 27 studies conducted in Africa, of which 6 were sampled to be included in the synthesis. The aim of the current review was to synthesise all 27 studies conducted in Africa to determine if the inclusion of additional African studies will change any of the themes, concepts, or theory generated in the Cochrane review.

The methods of the larger Cochrane review by Cooper and colleagues are reported elsewhere (see Related Summaries, below). The Cochrane review had developed a 4-theme framework for understanding the factors influencing caregiver views and practices regarding childhood vaccination. The present study used this as an a priori framework and analysed the data against it. The "best fit" framework synthesis approach allowed them to test this framework and explore how it might be potentially strengthened and/or refined by data from a larger number of studies conducted in Africa.

The present review (of 27 studies from different countries and types of settings in Africa) found that parents' views and practices regarding childhood vaccination in Africa were influenced by various factors, which the researchers categorised into 5 themes - namely:

1. Ideas and practices surrounding health and illness - e.g., 4 studies that were conducted in Ethiopia, Malawi, Nigeria, and Togo found that religious beliefs that some parents had led them to less accept childhood vaccination.
2. Social communities and networks - e.g., 3 studies revealed that caregivers' acceptance of childhood vaccination was influenced by community members, including other parents, relatives, peers, neighbours, and other important members of the community. In Uganda, some mothers were stopped from vaccinating their children because the husband had more faith in traditional medicine than in immunisation.
3. Political events, relations, and processes - e.g., generalised decline in trust of authority and expert systems; agendas and interests underpinning the expert systems implicated with vaccination; current and past controversies (e.g., around the boycott of polio vaccine in Nigeria); and marginalisation, inadequate public services, and priority misalignment.
4. Access-supply-demand interactions - e.g., socio-economic challenges in accessing vaccination services; undesirable features of vaccination services and delivery and logistics; and interactions with frontline healthcare workers (e.g., some parents in Chad, Ethiopia, Republic of Guinea, and Uganda complained about healthcare workers' attitude towards them during the vaccination process).
5. Lack of information or knowledge - e.g., a study in Chad revealed that some parents were not informed about vaccination; they only heard about it from the ordinary people in the streets. Some parents in Guinea also cited lack of knowledge, poor understanding of health education, and misperception of side effects of vaccines, as some of the reasons that discourage them from vaccinating their children fully.

All these themes were also identified in the Cochrane review except for theme 5 (lack of information or knowledge), which the researchers called "not surprising at all because the review was focusing on Africa, a continent compromising of many low and middle-income countries facing many challenges such as limited human resources and low level of health literacy....Comprehensively understanding the influencing factors in Africa may therefore necessitates considering issues related to knowledge and information."

As with the Cochrane review, the present paper proposes that decision makers consider the following questions when planning and implementing interventions for reducing vaccine hesitancy and increasing vaccine acceptance and uptake:

• Have you considered how the intervention(s) could be tailored to the specific health beliefs and practices of parents in your setting - for example, through immunisation communication that acknowledges, aligns with, and builds on parents' specific health beliefs and practices?
• Have you considered whether the intervention(s) might involve the social groups to which the parents in your setting belong - e.g., by involving influential people within those groups (e.g., key opinion leaders) in the design, planning, and/or implementation of the intervention(s)?
• Have you considered whether the intervention(s) could be tailored to the specific reasons for parents' mistrust, such as developing dialogue-based approaches that invite open discussion or providing a broader range of essential services or commodities along with vaccination? Alternatively, have you considered working with groups or individuals known by parents to be trusted sources of information (e.g., non-governmental organisations, local opinion leaders, etc.) and possibly involving them in the design, planning, or implementation of the intervention(s)?
• Have you considered whether the intervention(s) could target the specific barriers parents face in accessing immunisations, such as providing outreach immunisations or mobile immunisation teams?
• Have you considered whether the intervention(s) could be tailored to address specific characteristics of immunisation services that might negatively impact parent acceptance of immunisation in your setting? For example, could the logistical procedures that parents must follow for vaccination possibly be redesigned to better meet parents' needs and circumstances?
• Have you considered intervention(s) that specifically reach healthcare workers - for instance, by making them aware of the influence their interactions with parents may have, providing them with training in communication skills or increased supervision and support, or adapting the kinds of vaccination information healthcare workers have access to and provide to parents?
• Have you considered intervention(s) that specifically address parents' lack of information or knowledge regarding childhood vaccination - for instance, by providing vaccine information that informs and educates parents about the benefits of vaccines and the process of vaccination?

Asking these questions, in the context of the review, could help programme managers, policy and decision makers, and other stakeholders in Africa promote acceptance and uptake of childhood vaccination by developing and implementing interventions that are tailored to address lack of knowledge and information around vaccines.