Understanding Multilevel Barriers to Childhood Vaccination Uptake among Internally Displaced Populations (IDPs) in Mogadishu, Somalia: A Qualitative Study

"Policy and community engagement is necessary for uptake of timely vaccination and improvement in health outcomes in this vulnerable IDP population."

Disparities in vaccination coverage exist in Somalia, with internally displaced persons (IDPs) being among the groups with the lowest coverage. Most IDPs in these camps are from marginalised or minority clans. Humanitarian actors are increasingly promoting community participation to improve health outcomes among such groups. In that vein, these researchers implemented an adapted participatory learning and action (PLA) intervention, which focused on routine vaccinations among displaced populations living in Mogadishu IDP camps. A cluster-randomised controlled trial (see Related Summaries, below) found that the intervention was successful in improving maternal knowledge and vaccination coverage but unsuccessful in improving timely vaccination. The researchers conducted a qualitative study to understand this result and to analyse the multi-level barriers to routine childhood immunisation uptake. This paper shares the findings of the process evaluation.

The study was conducted in IDP camps located in the Afgooye Corridor in Kahda district, Mogadishu. Abaay-Abaay groups (AAG), also called "Abay Siti" are all-female community groups that are found in many parts of Somalia. They are spontaneously formed by interested women and have traditionally focused on blending Somali custom with religious activities, typically centred around supporting each other and their communities. The groups are headed by an elderly woman known as Khalifada, who should be familiar with local history and Islamic teaching. After obtaining an invitation from each Khalifada, a trained facilitator guided weekly AAG group participants through an adapted 4-phase PLA cycle. Groups used participatory methods such as locally developed picture cards, games, and stories to identify and prioritise child health problems for under-5 children. They then developed and implemented locally available strategies to address those child health problems.

This qualitative study used observation data from 40 PLA group discussions with female caregivers and from interviews with nine vaccination service providers and six policymakers. The researchers also reviewed national-level vaccine policy documents and assessed the quality of health facilities in the study area. The socio-ecological model (SEM) was used to structure the analysis. The SEM acknowledges that a person's behaviour is influenced by five over-arching domains; the findings of the study are organised accordingly:

• Individual-level barriers - Caregivers' lack of knowledge, mistrust of vaccines, concerns about side effects, and costs (e.g., of transportation).
• Interpersonal-level barriers - Influence of family members such as husbands and mothers-in-law, and lack of decision-making autonomy by female caregivers.
• Community-level barriers - Cultural and traditional norms such as observing Umul (40-day seclusion period after giving birth), not vaccinating a child with a boil or on a hot day, or being evicted to a spot far from a health centre.
• Organisational-level (health system) barriers - Long waiting times, vaccine stockouts, long distances, language barriers, and hesitancy to open multi-dose vials.
• Policy-level barriers - Lack of clarity about eligible age of routine vaccinations, restriction of catch-up vaccinations, and age restrictions for certain antigens. For example: By the time the child is brought for their first vaccination after 40 days, they are already due for oral polio vaccine dose 1 (OPV1) and are therefore not given OPV0 (OPV birth dose), which leads to the child not being vaccinated on time even if they get the rest of the vaccines in the primary series. The policy needs to acknowledge this cultural context and be flexible to the needs of caregivers who may not be able to attend the health facility at the "right" time.

Thus, this study shows that it is important to address both demand and supply side issues in interventions. The PLA intervention largely focused on addressing demand-side barriers to vaccination, and groups were unable to address many health systems and health policy issues. The researchers point out, for example, that the Somalia Expanded Program on Immunization (EPI) policy and practice should be brought in line with guidance from the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization (SAGE) in acute humanitarian emergencies. SAGE recommends expansion of vaccination target groups during emergencies to include older children and adults. More research is necessary to understand the reasons why the Somali EPI policy does not follow WHO guidance. More research is also needed to understand the reasons for the dissonance between policy and practice about eligible ages for both routine and catch-up vaccination and the opening of multi-dose vials.

In addition, this study showed that forced evictions are common among IDPs and they can experience multiple evictions. This has the potential to disrupt vaccination services for already vulnerable groups. Health agencies should consider tracking evicted camps from their catchment areas and continuing vaccination through mobile teams. Mobile clinics would also enable vaccinations to reach children who were born at home or during the postpartum seclusion period.

With regard to communication implications, the study finds that caregivers sometimes have limited capacity to influence and enact decisions about their child's health, and their decisions are often influenced by community norms and beliefs. Therefore, vaccination programme designers should implement interventions that engage families and communities to improve the success of such interventions. Previous studies have shown that grandmothers and fathers are key influencers of maternal and child health and should therefore be included in interventions.

In conclusion: "Complex and interrelated factors affect childhood vaccination uptake among IDPs in Somalia. Interventions that address multiple barriers simultaneously will have the greatest impact given the complex nature of vulnerabilities in this population. There is a need to strengthen the health system and connect it with existing community structures to increase demand for services. [The]... research highlights the importance of formative research before implementing interventions. Further research on the integration of health service strengthening with PLA to improve childhood vaccination among IDPs is recommended."