"I'll Take Them Another Day": A Qualitative Study Exploring the Socio-behavioral Complexities of Childhood Vaccination in Urban Poor Settlements

"Community-derived and context-specific approaches that address the complex interaction between socio-behavioral and other contextual factors need to be tested and applied to improve the timely uptake of childhood vaccinations among marginalized populations."



Marginalised populations, such as those in urban slums, remote rural areas, or war-prone areas, are at higher risk of being unvaccinated. A multidimensional perspective considering demand- and supply-side barriers is pivotal in reversing declining childhood vaccination uptake. Exploring the social and behavioural dynamics that influence the demand for childhood vaccination facilitates the development of tailored interventions that consider cultural norms and community dynamics. Such interventions are more likely to be accepted and embraced by communities. This study explored the behavioural and social factors influencing childhood vaccination uptake in urban informal settlements in Nairobi, Kenya. Such settlements are characterised by highly dense residential spaces marked by overcrowding, limited access to essential services, and inadequate infrastructure.



The study's conceptual framework is the Theory of Planned Behavior (TPB), which encompasses three fundamental constructs: attitude (the individual's positive or negative evaluation or appraisal of the behaviour), subjective norms (perceived social pressure that encourages or discourages the behaviour), and behavioural control (perception of how easy or challenging it is to perform the behaviour). The constructs are posited to influence an individual's intention to engage in a specific behaviour, consequently affecting their actual behavioural performance.



Five focus group discussions (FGDs) were conducted between October 3 and December 1 2022 with 39 caregivers of children under five years of age residing in informal settlements. The TPB guided the structuring of the FGD questions. From the analysis, four main thematic categories were derived:



1. Attitude: All interviewees appeared to have basic knowledge of the benefits of vaccination in disease prevention. Most participants indicated they knew about some vaccine side effects. Mistrust in the quality of vaccines was highlighted as a contributing factor to the failure to take children for vaccination and represented community perspectives rather than individual participants' experiences. Caregivers in some religious formations did not immunise their children because they were forbidden or believed in protection through prayer. Cultural beliefs also contributed to vaccination delays. For instance, there was fear of adverse effects of injections where a child had been looked at with "evil eyes". Such beliefs were perceived to vary based on tribe, customs, and knowledge. Emotional factors also played a role: Parental love was highlighted as a powerful positive attitude that promotes vaccination and motivates caregivers to vaccinate their children. Some participants stated that they would feel bad or regret if their child developed a disease due to their failure to take the child for vaccination.



2. Subjective norms: Family members, friends, and neighbours were influential in vaccination decisions. A few participants pointed to their peers' disapproval of mass vaccination campaigns that influenced their decisions to vaccinate their children. Caregivers' concerns about being judged by peers and providers caused some not to seek vaccination services. On the other hand, some participants reported ignoring negative advice from their social networks. Decisions to disregard negative comments from peers were based on various factors, including personal beliefs and access to accurate information.



3. Perceived behavioural control factors: Caregivers' self-control was influenced by competing work demands and financial constraints. Work commitments were highlighted as a critical factor affecting the timeliness of vaccinations. Past experience with vaccination contributed to caregiver vaccination decisions. Although mothers were responsible for deciding whether children should receive vaccines, their ability to choose was limited by a lack of autonomy on financial matters in the household.



4. Practical factors: Challenges associated with accessing vaccination and healthcare provider-related factors influenced timely vaccination uptake. Poor access to public facilities in informal settlements and the need for transport funds led caregivers to seek vaccination from nearby private facilities. However, the high cost of immunisation at the private facilities served as a deterrent. Negative attitudes on the part of healthcare providers were also identified as a primary reason for missed vaccinations. Mothers whose children had missed previous vaccination appointments felt mistreated when they finally presented to the health facilities. Others worried about being judged because their baby was underweight or being reprimanded for not spacing out their children through family planning.



Thus, this study suggests that various social, behavioural, cultural, and contextual factors influence caregiver vaccination decisions in the urban economically poor setting under investigation. Consistent with previous research, the findings point to influences from healthcare providers, family, and friends on caregivers' decision to vaccinate their children. Descriptive norms are the perceived prevalence or typicality of a given behaviour, and injunctive norms are the perceived degree of social approval or disapproval of the behaviour. These distinct forms of social influence can be independently or concurrently targeted by a health promoter keen on understanding, predicting, and influencing health-seeking behaviour. Health messaging needs to take cognisance of such social influences and be tailored to the cultural dynamics in the informal settlements.



Gender-related barriers were an important social factor influencing timely childhood vaccination uptake in informal settlements. Though the mothers were identified as the primary decision-makers in vaccinating their children, their male partners played a crucial role in supporting the vaccination process. Involving fathers in decision-making and addressing their concerns about vaccines can help ensure that more children are vaccinated and protected. In general, tailoring messaging to address specific caregivers' concerns can help to alleviate fears or misconceptions they may have about vaccines.



Interventions are also needed, particularly in economically poor urban areas, to minimise missed vaccinations due to caregivers' fear of being judged or stigmatised by healthcare providers or peers. Such interventions should promote non-judgmental attitudes towards caregivers, including training providers to provide respectful and supportive care to all caregivers, regardless of their social status or other factors.



"In conclusion, the findings underscore the complex interplay of socio-behavioral factors in caregivers' vaccination decisions for their children....The results also emphasize the importance of addressing barriers such as affordability, gender-related factors, information gaps, and healthcare provider attitudes to enhance vaccination uptake effectively."