Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study

Community perceptions of barriers and enablers to 2YL vaccination provide a snapshot of an active diffusion process as new practices gradually displace older embedded ones and practical costs and benefits of later vaccination are reevaluated. Key Findings We document community perspectives on barriers and enablers to second year of life (2YL) vaccination in Ghana in settings with high uptake of infant vaccination but still lagging coverage rates of the second dose of measles-containing vaccine 4 years after its introduction. Key enablers included 2YL integration into an established well-child visit and robust vaccine acceptance built on decades of observed safety and efficacy of infant vaccination programs. Key barriers included questions about whether older children benefited as much from vaccination, increased cost, inconvenience, and potential competition for time, household resources, and maternal health when 2YL visits overlapped with follow-on pregnancies. Some caregivers experienced veiled or direct criticism from community members and even health care personnel for bringing in children “too old” to be vaccinated, suggesting the persistence of previous norms encouraging all children to be fully vaccinated before their first birthday. Key Implications Building robust community demand for 2YL vaccination to the level achieved for Expanded Programme for Immunization infant vaccines requires time and active promotion to diffuse new practices and supporting norms among caregivers and care providers alike. Integrating a childhood vaccination option into antenatal care services could reduce competition for time and resources between maternal and child health and lower the cost of access to 2YL services. ABSTRACT Introduction: Coverage rates for second year of life (2YL) vaccination still lag behind infant vaccination in most settings. We conducted a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after introducing the second dose of the measles-containing vaccine. Methods: We conducted 26 focus group discussions in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model theory. We conducted a thematic analysis of the discussion using NVivo software. We use Normalization Process Theory to contextualize results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunization schedule following 2YL introduction. Results: Routine immunization for infants enjoys resilient demand, grounded in strong community norms despite surprisingly low levels of vaccine literacy. Despite best practices like integration with the established 18-month “weighing visit,” demand for 2YL vaccination is still conditional on individual awareness and competition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be “too old” to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming “too late. ” Conclusion: Closing the 2YL vaccination coverage gap will ultimately require modifying embedded norms among caregivers and health care providers alike. Time is necessary but not sufficient to reach this goal. Progress can be accelerated by increasing the level of community and institutional engagement and adapting services where possible to minimize added costs to caregivers of vaccinating older children.