The value of longitudinal qualitative approaches in vaccination pilot studies
Authors: Violet Naanyu
Journal: The Lancet Global Health (2024)

Malaria in children remains a killer disease in Africa, and more innovative strategies are needed to reduce morbidity and mortality, including the adoption of international and national guidelines and dedicated research efforts on malaria prevention.1Friedman-Klabanoff DJ Adu-Gyasi D Asante KP Malaria prevention in children: an update.Curr Opin Pediatr. 2024; (published online Jan 23.)doi: 10.1097/MOP.0000000000001332Crossref PubMed Google Scholar In The Lancet Global Health, Jenny Hill and colleagues2Hill J Bange T Hoyt J et al.Integration of the RTS,S/AS01 malaria vaccine into the Essential Programme on Immunisation in western Kenya: a qualitative longitudinal study from the health system perspective.Lancet Glob Health. 2024; (published online Feb 28.)https://doi.org/10.1016/S2214-109X(24)00013-5Google Scholar present a commendable investigation of factors that shaped delivery and uptake of a malaria vaccine during a pilot introduction in Kenya. To ensure the success of these types of vaccination pilot programmes, it is crucial to comprehend supply-side challenges as well as demand-side challenges such as public attitudes and practices, which are often site-specific and complex. While the authors report that they investigated both contextual and dynamic factors that influenced delivery and uptake of the malaria vaccine, the demand side is not adequately addressed in this current study. For instance, voices from community-level stakeholders (eg, caregivers) would have made their article more inclusive, and the experiences of patients would not have been inferred from health-care workers. Many barriers to childhood vaccination in Africa have been reported,3Mbonigaba E Nderu D Chen S et al.Childhood vaccine uptake in Africa: threats, challenges, and opportunities.J Glob Health Rep. 2021; 5e2021080Google Scholar and these barriers would be especially important during the pilot phases of a malaria vaccination programme. For instance, on the demand side, poverty and limited access to health care (eg, fares), misinformation on the vaccine, and inadequate public awareness of the vaccination programmes further compound the issue. On the supply side, long distances to the health facilities, vaccine stock-outs, size and competency of providers' teams, and long waiting time can discourage uptake and completion of multiple doses. Thus, to sufficiently understand factors influencing the uptake of vaccines, we need to apply the socioecological model4Stokols D Translating social ecological theory into guidelines for community health promotion.Am J Health Promot. 1996; 10: 282-298Crossref PubMed Google Scholar as we unpack logistical, political, economic, and sociocultural barriers to the implementation of vaccine programmes.3Mbonigaba E Nderu D Chen S et al.Childhood vaccine uptake in Africa: threats, challenges, and opportunities.J Glob Health Rep. 2021; 5e2021080Google Scholar Consequently, we should engage all relevant stakeholders (from the household level to the national offices) to achieve higher vaccination uptake and full dose completion rates,5Jarrett C Wilson R O'Leary M Eckersberger E Larson HJ Strategies for addressing vaccine hesitancy–a systematic review.Vaccine. 2015; 33: 4180-4190Crossref PubMed Scopus (659) Google Scholar irrespective of whether the programmes are silos or integrated into existing health service structures. The study by Hill and colleagues2Hill J Bange T Hoyt J et al.Integration of the RTS,S/AS01 malaria vaccine into the Essential Programme on Immunisation in western Kenya: a qualitative longitudinal study from the health system perspective.Lancet Glob Health. 2024; (published online Feb 28.)https://doi.org/10.1016/S2214-109X(24)00013-5Google Scholar shows the advantageous use of mixed qualitative methods and longitudinal approaches to better appreciate and query the piloting and rollout of health interventions such as vaccine programmes. This is highly commendable and to be encouraged, because qualitative approaches allow investigators to iteratively and elaborately ask questions on how, why, and under what circumstances any intervention succeeds (or fails) in a specific milieu.6Busetto L Wick W Gumbinger C How to use and assess qualitative research methods.Neurol Res Pract. 2020; 2: 14Crossref PubMed Scopus (271) Google Scholar Furthermore, the implementation research approach is highly recommended for vaccine programmes because it helps investigators fully understand factors affecting the successful implementation of health interventions by assessing coverage, acceptability, adoption, fidelity, equity, cost, and sustainability.7Nilsen P Making sense of implementation theories, models and frameworks.Implement Sci. 2015; 10: 53Crossref PubMed Scopus (2132) Google Scholar Moreover, reflexivity is an important consideration in this type of research.8Olmos-Vega FM Stalmeijer RE Varpio L Kahlke R A practical guide to reflexivity in qualitative research: AMEE Guide No. 149.Med Teach. 2022; 7: 1-11Google Scholar Qualitative research teams are often deeply engaged with their field sites, research participants, and the emergent data. In this study, participants were aware of the objectives of the qualitative evaluation and became familiar with the study team during the data collection phases. To ensure the validity and reliability of findings, it is important to transparently report on how relationships between researchers and participants affect willingness to consent, data collection procedures, and the data that are ultimately collected. Qualitative researchers need to continuously memo all contextual, process, and logistical factors that might influence their study, as well as how they mitigate associated biases. 8Olmos-Vega FM Stalmeijer RE Varpio L Kahlke R A practical guide to reflexivity in qualitative research: AMEE Guide No. 149.Med Teach. 2022; 7: 1-11Google Scholar The significance of a study such as the one presented by Hill and colleagues2Hill J Bange T Hoyt J et al.Integration of the RTS,S/AS01 malaria vaccine into the Essential Programme on Immunisation in western Kenya: a qualitative longitudinal study from the health system perspective.Lancet Glob Health. 2024; (published online Feb 28.)https://doi.org/10.1016/S2214-109X(24)00013-5Google Scholar lies in the transparent reporting of the implementation process and all methodologies used. The lack of detailed reporting makes it difficult for other global clinicians and researchers to fully appreciate the methods used, the justification for the choices made, and the possibility of replicating the project in similar contexts. Furthermore, given the study focus, it is important to balance the reporting to ensure lessons learned can be harnessed for future vaccination initiatives. The investigators failed to fully consider and report both the operational challenges experienced, and opportunities noted during the integration of the malaria vaccine into the essential programme on immunisation in Kenya. Several studies and strategies have been developed and applied to combat malaria, including continued use of mosquito repellents, insecticides, treated bed nets, and protective clothing.9Fischer PR Bialek R Prevention of malaria in children.Clin Infect Dis. 2002; 34: 493-498Crossref PubMed Scopus (0) Google Scholar The new vaccine programmes that are regional and risk-stratified and seasonal malaria chemoprophylaxis show great promise.1Friedman-Klabanoff DJ Adu-Gyasi D Asante KP Malaria prevention in children: an update.Curr Opin Pediatr. 2024; (published online Jan 23.)doi: 10.1097/MOP.0000000000001332Crossref PubMed Google Scholar Continued investment in malaria vaccine research; implementation research to assess the reach, effectiveness, adoption, fidelity, and sustainability of vaccine programmes; and evidence-informed new guidelines will all increase the possibility of successful malaria prevention and reduced deaths. As we integrate the malaria vaccine initiatives within existing health structures, successes, challenges, approaches, and adaptions ought to be meticulously captured and shared widely. Only then can we appreciate the impact of such integrations on other services and what is needed to ensure full integration and scale-up. I declare no competing interests. Integration of the RTS,S/AS01 malaria vaccine into the Essential Programme on Immunisation in western Kenya: a qualitative longitudinal study from the health system perspectiveIntegration of RTS,S/AS01 into immunisation services in western Kenya presented substantial operational challenges most of which were overcome in the first 2 years, providing important lessons for other countries. Programme expansion is feasible with intensive staff training and retention, enhanced supervision, and defaulter-tracing to ensure uptake of all doses. Full-Text PDF Open Access