Barriers and Facilitators to Nationwide Implementation of the Malaria Vaccine in Ghana

"The context of scaling up the vaccine should encompass communication and understanding of the comprehensive intervention approach to reduce vaccine hesitancy."

Despite interventions such as antimalarial drugs, bed nets, and insecticides, malaria remains a leading cause of morbidity and mortality in children below the age of 5 years in sub-Saharan Africa. To further curb the burden of malaria, the Malaria Vaccine Pilot Implementation Project (MVIP) in Ghana commenced in May 2019. The 2019 Ghana Malaria Indicator Survey indicated that 90% of caregivers would be willing to have their children vaccinated with the malaria vaccine. However, the COVID-19 pandemic and development of multiple COVID-19 vaccines has led to an increase in vaccine hesitancy globally. Using qualitative methods, this study examined various factors that may influence or hinder the nationwide implementation of the malaria vaccine, if approved, in Ghana.

This study uses a force field analysis (FFA) framework, developed by social psychologist Kurt Lewin in the 1940s, to identify factors (forces) that lead to a change that is capable of shaping policy processes. Within this framework, the researchers conducted in-depth interviews with 12 key individuals (national, research/academia, and programme implementing partners) in the public health sector in Ghana from October 2018 to February 2019.

The researchers found that driving forces to scale up the vaccine into a routine health system included: the disease burden of malaria deaths in Ghana, the efficacy of the vaccine, evidence for the feasibility of vaccine delivery, and stakeholder involvement. For example, the latter element reflects the fact that the nationwide implementation process of any vaccine is lengthy and requires sufficient dissemination of information among involved groups and bodies. Various stakeholders are attempting: to increase awareness of evidence-based data for the remaining phases of the MVIP; to enhance transparency, communication, and involvement; and to ensure sociocultural sensitivity of disseminated information between the bodies involved and caregivers of children who will receive the vaccine.

To date, within the Expanded Programme on Immunization (EPI), interviewees noted that there have been positive experiences of implementing new vaccines in Ghana, especially when parents/caregivers are involved in the process: "To us, our experience with new vaccines has been very good but then it needs the preparatory activities to train the staff, to inform the communities, to educate them, so they know about the vaccine."

On the other hand, the needed logistics, funding, administration of the four-dose vaccine, and follow-up were identified as potential barriers. For instance, from the interviews, the MVIP needs to know if the four doses can be delivered effectively within Ghana's routine immunisation schedule effectively, including responding to unanswered safety questions or doubts expressed by the public.

In terms of communication recommendations going forward, the research highlights the need for sufficient resources for clear communication channels, stakeholder involvement, and a collaboration of various stakeholders at the international and in-country levels. Under experimental conditions, the administration of the vaccine and follow-up were the responsibility of health workers, who brought children with their caregivers to health facilities. However, in the scale-up, the onus will be on caregivers, so measures will need to be put in place to ensure caregivers are willing and able to bring children to health facilities for vaccination. To this end, the Ghana Health Service through the health promotion division "should intensify public education about the efficacy of the vaccine throughout the country. Social mobilization is also needed to educate mothers or caregivers on the importance and acceptance of having children take all four doses, including promoting follow-up on taking the four doses."

Specifically, and in light of the risk of vaccine hesitancy, the researchers suggest employing social and behaviour change communication (SBCC) that is targeted, participatory, and grounded in evidence-based data from the MVIP to strengthen community engagement and improve vaccine acceptance. They explain: "The nature of community engagement is likely to have an impact on the populace perception of the vaccine. Conversations on the feasibility, impact and safety of the vaccine could also be held to address the concerns of caregivers. This participatory action could potentially increase caregivers' adherence to coming to health facilities with their children for the vaccine administration..."

In conclusion: "The results from this qualitative study are not generalizable to other stakeholders or populations, but the results are similar to those from other studies conducted in Kenya, South Africa and Gambia on the introduction of the rotavirus and pneumococcal vaccines, and provide important considerations for planning the scale up of a vaccine..."