Using Community-Based, Participatory Qualitative Research to Identify Determinants of Routine Vaccination Drop-Out for Children under 2 in Lilongwe and Mzimba North Districts, Malawi

"The strengths of this study are rooted in the CBPR [community-based participatory research] approach; the caregiver researchers drew from their own vaccination experiences and their community connections to bring community-centred insights to the data collection and analysis processes."

In Malawi, while routine vaccination coverage increased between 2016 and 2019, coverage for almost all doses on the routine schedule declined by approximately 15 percentage points between 2019 and 2022, in large part due to the COVID-19 pandemic. In this context, the present study used community-based participatory research (CBPR) to identify and describe the determinants of vaccination drop-out from the perspectives of caregivers and health workers in Malawi.

The study was conducted between July 2022 and February 2023 in Lilongwe and Mzimba North districts, representing urban and rural settings, respectively. Eight health facilities with the highest drop-out rates were selected. Participants included caregivers of partially vaccinated (n=38) and fully vaccinated (n=12) children between 25 and 34 months, as well as Health Surveillance Assistants, or HSAs (n=20), who deliver vaccines. Vaccination status was determined by whether or not the child had completed all 16 doses on the routine immunisation schedule by age 2.

VillageReach adapted the World Health Organization (WHO)'s Behavioural and Social Drivers (BeSD) of vaccination framework, adding components from the United Nations Children's Fund (UNICEF)'s immunisation journey. This model served as the framework to guide data collection and analysis.

CBPR is an approach that engages community representatives throughout the research process, helping to minimise bias and reduce power dynamics during data collection and facilitating development of contextually sensitive and community-centred findings. VillageReach hired and trained 4 caregivers from the study communities ("caregiver researchers") to lead data collection and assist with analysis. They participated in a 5-day training on qualitative methods and research ethics.

The caregiver researchers conducted photo-elicitation interviews with caregivers, asking to reflect on their immunisation visits and to think about photos or depictions that might represent their immunisation journey. In addition, HSAs participated in text message exchanges over a 3-week period and semistructured interviews to share their experiences delivering childhood immunisations and their perspectives on vaccination drop-out. Finally, the caregiver researchers conducted 16 observations of immunisation sessions at both static and outreach sites for all 8 facilities.

The study identified 5 principal drivers of routine vaccination drop-out:

1. Poor caregiver knowledge of the vaccine schedule and how many vaccines are needed for full vaccination - Caregivers explained that when they went for vaccinations, they might arrive after the health talk was delivered, or said that the HSAs sometimes skipped the health talk entirely. Furthermore, some caregivers shared that they felt uncomfortable speaking up if they had questions. The HSAs noted that when facilities are busy, they do not have enough time to speak individually with caregivers. Caregivers and HSAs said these challenges resulted in caregivers having poor knowledge of the vaccine schedule or of how many vaccines are needed for full protection, which can cause them to drop out early.
2. Caregivers' fear of repercussions after not following vaccination guidelines - Even when caregivers understood that vaccination is not mandatory, they still feared repercussions for not following these guidelines. In these cases, caregivers may decide not to return to the facility to avoid being reprimanded. Caregivers in Lilongwe were also hesitant to return to the facility after losing or damaging the child's health card.
3. Rumours and concerns if vaccines are repeated or new ones are introduced - Many caregiver participants said that their children have received the same vaccines multiple times. This is largely due to widespread campaigns (e.g., for polio), during which HSAs often go door-to-door and deliver vaccines to all children regardless of whether or not their health cards show that they already received the vaccine. The combination of COVID-19 rumours, multiple new vaccines being introduced, numerous recent campaigns, and the perception of vaccination being forced on people has created an environment in which some caregivers worry that the government is using vaccination for nefarious purposes and have lost trust in vaccines and other health services.
4. High opportunity cost of health facility visits, exacerbated by wait times, stockouts, and missed opportunities - Caregivers may feel they are wasting time by going to the facility if they are not confident they will receive services. The benefits of vaccination are no longer worth the time and effort required, especially when caregivers have other pressing commitments or are concerned about losing their jobs.
5. Limited family support and vaccination burden placed largely on mothers - In general, most caregivers said their family members, including husbands, encouraged them to vaccinate their children. Most also described a supportive community environment around vaccination in which they received encouragement and reassurance from other caregivers in their community. However, the burden of bringing the child to and from vaccinations still falls largely on the mother due to gender norms.

This study showed that barriers and drop-out determinants arose across all categories of the BeSD Model and were consistent with those found in other studies. For example, many studies have documented that COVID-19 vaccine hesitancy has spilled over into routine immunisations, resulting in caregivers having reduced confidence in childhood vaccines. However, these data further suggest that at least in the context of Malawi, campaigns and new vaccines being introduced to the country might exacerbate this phenomenon.

Per the researchers, this study's findings may have implications on vaccination practices in Malawi and beyond. For instance:

• At the community level, it is critical that communities provide input on how services, especially outreach, could better fit around their busy schedules. Community-level social listening could help to gain better insight into caregivers' concerns on a routine basis and quickly address rumours as they emerge. Finally, there is a need for increased community mobilisation that reaches: (i) men: to address social and gender norms that overburden mothers (ii) employers: to help caregivers manage conflicting responsibilities.
• At the facility level, a sufficient and motivated workforce is needed so that HSAs have time to provide personalised education to caregivers and are motivated to create a welcoming environment for them. Resources shortages need to be addressed, and infrastructure needs to be improved, especially for outreach sessions, many of which have no shelter from the elements.
• At the national level, there may be a need to revisit and standardise certain practices, including vaccine education and messaging, especially when new vaccines are introduced. Practices related to vaccine wastage and how to handle caregivers who are missing a health card or children who have fallen behind schedule need to be more consistent and transparent. Finally, it could be beneficial to implement a national electronic immunisation registry.

In conclusion: "Immunisation interventions should be tailored to address drivers of drop-out in the community, the health facility and beyond. Service quality, timeliness and reliability need to be improved, and tailored messaging and education are needed, especially in response to COVID-19-related misinformation and introductions of new, routine vaccines."