Qualitative Assessment of Caregiver Experiences when Navigating Childhood Immunisation in Urban Communities in Sierra Leone

"The findings show that health system interventions, community engagement and vaccination outreach may need to be tailored for urban LMIC settings."

In Sierra Leone, the 2014-2016 Ebola epidemic disrupted the delivery of essential health services, including immunisation services, especially in urban areas. Assessment of immunisation barriers in urban areas in low- and middle-income countries (LMICs) like this one has identified a range of practical and social issues, such as the lack of trust in the health system among vulnerable groups and weak community engagement and outreach. The purpose of this exploratory qualitative assessment was to understand the real-world experiences of caregivers of vaccine-eligible children as they navigate urban immunisation services in the Western Area Urban (WAU) district, Sierra Leone.

The United Nations Children's Fund (UNICEF) and partners developed the Caregiver Journey Framework (see Related Summaries, below) to guide countries in understanding the experiences, processes, and structures that shape how caregivers seek and receive health services for their children, including essential immunisation. Based on that framework, the researchers developed the Immunisation Caregiver Journey Interviews (ICJI) approach, which they used to explore the following domains: decision making and preparation, making the journey, experiences during vaccination visit, postvaccination experiences, intentions to return, and perceptions of immunisation promotion activities in the community.

Participants in the August-September 2018 interviews included caregivers of children ages 6-36 months old from slums (n=8, half fully vaccinated and half undervaccinated) and other urban communities (n=8, half fully vaccinated and half undervaccinated) in the capital city of Sierra Leone (in the WAU district).

Three themes emerged from the interviews around vaccination enablers (see table 1 in the paper), vaccination barriers (see table 2), and direct recommendation to improve vaccination uptake (see table 3). There were no notable differences in themes between slums and other urban communities. In brief:

1. Enablers: Emotional enablers of vaccination were evident in caregivers' sense of parental obligation to their children, desire for a strong and healthy baby, and anticipation of reciprocal benefits in children's ability to take care of them (the parents) later in life. Practical enablers were found in the diversity of immunisation reminders (e.g., immunisation cards and community outreach campaigns), information access and information trust (with a focus on nurses), engagement of fathers in vaccination, positive experiences with health workers, and postvaccination information sharing in the community.
2. Barriers: Underlying barriers to childhood vaccination were due to practical constraints such as overcrowding and long wait times at the clinic, the feeling of being disrespected by health workers, the expectation of that health workers be given money for free services, and fear of serious vaccine side effects.
3. Recommendations: To improve vaccination outcomes, caregivers desired more convenient and positive clinic experiences and deeper community engagement. For example, they recommended implementing community outreach campaigns for immunisation at regular intervals, with a focus on defaulters. In addition, caregivers wanted health workers and community leaders to be involved in immunisation promotion, along with the community health workers (CHWs).

In conclusion, the study suggests that health system interventions, community engagement, and vaccination outreach need to be tailored for urban settings. For instance, interventions at the health systems level are necessary to help discourage informal payments to health workers - a practice that may perpetuate vaccination inequities among economically poor caregivers who are unable to meet monetary expectations. Health workers and CHWs may benefit from periodic in-service training on how to effectively communicate vaccine safety and address concerns about adverse events following immunisation (AEFIs), which may contribute to vaccine hesitancy. At the household/family, level, the researchers call for additional assessments and interventions to explore and evaluate culturally appropriate ways to enhance the involvement of fathers in childhood immunisation in Sierra Leone and other similar LMIC settings.

Disclaimer: The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.