A qualitative interview study with parents to identify barriers and drivers to childhood vaccination and inform public health interventions.

Vaccination coverage in the Federation of Bosnia and Herzegovina, in Bosnia and Herzegovina, has been declining since 2014. This qualitative study aimed to identify barriers and drivers to childhood vaccination for parents. The COM-B (capability-opportunity-motivation-behavior) model was the underpinning theoretical framework. Face-to-face interviews with 22 parents of fully (n = 6), delayed/partially vaccinated (n = 9) and unvaccinated (n = 7) children were conducted. Interviews explored individual factors (capability-knowledge and skills; motivation-attitudes, confidence and trust) and context factors (physical opportunity-information, access, health systems; and social opportunity - social support, norms). Data were analyzed in NVivo using content analysis exploring differences in COM factors by vaccination status and location. Parents of fully vaccinated children typically reported individual and context drivers to vaccination. They accepted vaccination, trusted health workers, and were content with services. Parents of delayed/partially vaccinated children fell into two subgroups: (1) Those who accepted vaccination and attributed delays to their organizational skills or frustration with appointment times. (2) Those fitting the profile of "vaccine hesitant" - generally valuing vaccination and health worker advice, yet with concerns often triggered by media/social media. Parents of unvaccinated children mentioned individual and context barriers to vaccination, notably significant concerns about safety, some distrust of health workers and resentment of mandatory vaccination. Urban/rural differences included urban parents being more likely to report experiences with vaccine shortages and very few had received information leaflets. The study identified complex and inter-related barriers and drivers to parents' childhood vaccination behaviors. These insights have informed the development of tailored interventions to improve coverage.

Tailoring Immunization Programmes: using patient file data to explore vaccination uptake and associated factors.

Vaccination uptake in the Federation of Bosnia and Herzegovina (FBiH), in Bosnia and Herzegovina, is suboptimal. This study aimed to (1) assess vaccination coverage, timeliness and drop-out for children born in 2015 and 2016 and compare these with official administrative coverage estimates, (2) identify associations between characteristics of children/caregivers and vaccination uptake. This was a cross-sectional study based on patient files for children 12-23 months (n = 1800) and 24-35 months (n = 1800). Methods were adapted from the World Health Organization cluster survey methodology. A two-stage stratified sampling procedure was conducted in urban and rural strata. A structured paper-based form was completed by a pediatrician/nurse from randomly selected primary care centers and patient files. Estimates were based on weighted analysis with a 95% confidence interval to account for the survey sampling design. Vaccination coverage was consistent with administrative coverage levels for BCG, DTP and MMR, and lower for HepB; all considerably lower than regional targets. Children in urban areas had lower vaccination uptake. An assumption that anti-vaccination sentiment prevails among caregivers was not confirmed; only 2% of children were not vaccinated at all, instead challenges related to delays and drop-out. An assumption of caregiver concerns for the MMR vaccine was confirmed with low uptake and delays. The FBiH has experienced vaccination schedule changes due to supply issues; findings confirmed that sustainability in supply and schedule is high priority. These data are new and provide important information for developing strategies to increase uptake.

Identifying barriers and drivers to vaccination: A qualitative interview study with health workers in the Federation of Bosnia and Herzegovina.

BACKGROUND: Vaccination coverage in Bosnia and Herzegovina has been declining over recent years. A World Health Organization Tailoring Immunization Programmes (TIP) project is underway to gain insights into the underlying reasons for this, to develop tailored interventions. As part of TIP, this study aimed to investigate the views of health workers on their barriers and drivers to positive childhood vaccination practices. METHODS: Face-to-face qualitative interviews explored 38 health workers' views on vaccination coverage, their vaccination attitudes, and system, programme and institutional influences on their vaccination practices. The data were analysed using content analysis and organised by the COM (Capability, Opportunity and Motivation) factors. FINDINGS: Very few differences in barriers and drivers were evident between high and low coverage primary care centres or across different professional roles. Capability: Drivers included awareness of the risks of low vaccination coverage, regular use of the Rulebook and Order, knowledge of how to advise parents on mild side effects and recognition of the importance of good communication with parents. Key barriers were the use of false contraindications to postpone vacination and poor skills in tailoring communication with parents. Opportunity: Drivers were sufficient time for adminstering vaccination and good availability of vaccines. Several barriers were evident: lack of implementation of mandatory vaccination, no uniform recall and reminder system or system for detecting under-vaccinated children, staff shortages and lack of time to discuss vaccination with parents. MOTIVATION: Drivers were a belief in the value, safety and effectiveness of vaccination and seeing that they have an important role to play. Barriers were a tendency to blame external factors e.g. anti-vax movement and a fear of being blamed for adverse events. CONCLUSIONS: The study identified complex and inter-related barriers and drivers to health worker positive vaccination practices. These insights will now inform a process to identify and prioritize interventions.