Identifying Barriers and Drivers to Vaccination: A Qualitative Interview Study with Health Workers in the Federation of Bosnia and Herzegovina

A growing body of evidence exploring vaccine hesitancy and other reasons for suboptimal vaccination uptake has shown that the underlying causes are complex, context-specific, and vary by time, place, and vaccine. Thus, they must be studied locally to inform an effective response. Vaccination uptake in the Federation of Bosnia and Herzegovina (FBiH) has been declining over recent years. To gain insights into the underlying reasons for the suboptimal vaccination uptake in FBiH with a view to developing tailored interventions, the Institute for Public Health of the FBiH in 2018 initiated a project guided by the World Health Organization (WHO) Tailoring Immunization Programmes (TIP) approach. As part of TIP, this study aimed to investigate the views of FBiH health workers on their barriers and drivers to positive childhood vaccination practices.

Drawing on social sciences, ethnographic research techniques, and behavioural insights methodology, TIP offers countries a process through which to identify susceptible groups, diagnose barriers and drivers to positive vaccination behaviours, and segment populations according to behavioural determinants. The theoretical framework underpinning the TIP process is the COM-B model, which identifies the inter-linked factors of capability (physical, psychological), opportunity (physical, social), and motivation (reflective, automatic) as influencing health behaviour. (For details on TIP, see Related Summaries, below, and the summaries linked within that posting's own Related Summaries.)

As part of this qualitative study, conducted May 2017 to May 2018, 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 factors, which are illustrated in the paper with representative quotations. Selected findings:

• Capability: Poor awareness of FBiH vaccination coverage was evident, with only half of participants aware that it is low. There was a general understanding amongst participants that vaccines are safe, though a few health workers admitted to being affected by anti-vaccination messages in the media/social media. There was clear acknowledgement of the importance of good communication with parents about vaccination. This is seen to entail explaining the vaccination procedure to parents, building trust, serving as a voice supporting vaccination to counteract anti-vaccination messages in the media, helping parents make a decision and, for some health workers, ensuring that parents "cooperate". Some described a good relationship with Roma families and appeared to have the skills to liaise with this community and establish trustful relationships. Key barriers were the use of false contraindications to postpone vaccination and poor skills in tailoring communication with parents.
• Opportunity: Drivers were sufficient time for administering 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. Over half of the paediatricians stated they accept vaccination refusals for some children, delay vaccination for children who are not developing as expected for their age or weight, or routinely postpone vaccination when children have minor acute infections, despite knowing that these are false contraindications.
• Motivation: Drivers were a belief in the value, safety, and effectiveness of vaccination and seeing that health workers have an important role to play in communicating this. Barriers were a tendency to blame external factors and a fear of being blamed for adverse events. For example, when asked about the reasons for low vaccination coverage in FBiH, the predominant view amongst health workers was that this is due to the anti-vaccine movement, which is seen as well-connected and aggressive, leading to confusion, fear, and skepticism amongst parents. There seemed to be a sense of resignation, which did not motivate health workers to engage in discussions or use motivational approaches to reach parents who refuse vaccination for their child and engage with them.

Thus, this study "uncovers significant, complex and inter-related capability, opportunity and motivation barriers to positive childhood vaccination practices which could potentially contribute to the declining vaccination uptake experienced in FBiH." Its findings could inform the development of targeted interventions and policy changes to support health workers in their contribution to improving vaccination coverage in FBiH. For example, the health workers had inadequate communication skills to respond to parental hesitancy or vaccine refusals. Anti-vaccination lobbyism, grounded in alternative models of health, parental autonomy, conspiracy thinking, and distrust of expertise, is a relatively recent phenomenon in the Balkan countries, having spread from the West. Doctor-parent communication in this environment is likely to be challenging, and health workers need guidance on techniques to have productive vaccine discussions.

The insights from this study will inform a process to identify, prioritise, and advocate for theory- and evidence-informed interventions designed to increase vaccination coverage in FBiH.