Vaccination Decision-making among Mothers of Children 0-12 Months Old in Nigeria: A Qualitative Study

"The study has allowed a deeper insight into understanding what lies behind relevant antecedents of maternal vaccination behavior in Nigeria."

Nigeria is one of the 10 countries in the world where 4.3 million children under 5 are without complete immunisation due to factors including vaccine hesitancy. The goal of this study is to gain deeper insights into vaccination decision-making among mothers of children 0-12 months old in Nigeria using the 5C psychological antecedence model, gaining data on enablers and barriers of vaccination behaviour in an understudied setting. It is hoped that the study's outcomes can support the evidence-based design of appropriate interventions to address low vaccination uptake - not just in Nigeria but also in other countries in Sub-Saharan Africa (SSA).

The 5C model of vaccines hesitancy is composed of 5 psychological antecedents of vaccination behaviour:

1. Confidence is the trust in the effectiveness and safety of vaccines.
2. Complacency denotes low risk perception of vaccine-preventable diseases (VPDs) and vaccination deemed not a necessary preventive action.
3. Constraints exist when physical availability, affordability, or geographical accessibility negatively affect immunisation uptake.
4. Calculation refers to individuals' engagement in extensive information search and assessment of cost-benefit analysis of vaccination decisions.
5. Collective responsibility is the willingness to protect others by one's own vaccination decision or action.

In addition to the 5Cs, 2 additional constructs that proved relevant in previous work in Nigeria were used in this study: religion (i.e., compatibility of vaccination with religious beliefs) and masculinity (i.e., importance of father's approval).

To conduct focus group discussions, a simplified quota sampling approach was used to select mothers of children 0-12 months old in 4 geographical clusters of Nigeria's Federal Capital Territory. The data were collected from September 20-27 2019, based on an interview guide informed by the 5C model. The data were analysed using a meta-aggregation approach.

Many mothers had a positive attitude toward childhood immunisation. They perceived their children to be vulnerable to disease outbreaks, which motivated vaccination (complacency), they had great interest in seeking additional immunisation information (calculation), and they were aware that vaccination translates into overall community wellbeing (collective responsibility).

However, mothers reported low trust in vaccine safety and the healthcare system (confidence), and they experienced difficulties in prioritising vaccination over other equally competing priorities (constraints). Other constraints that influenced vaccination decision-making or behaviour of mothers were long waiting hours at the clinic, disrespectful attitude of healthcare workers (HCWs), and difficulties in dealing with adverse events following immunisation (AEFIs).

The mothers had a bias toward God as ultimate giver of good health (religion), and their husbands played a dominant role in vaccination decision-making (masculinity).

Based on the findings, the researchers suggest, for example, that:

• Building trust, not necessarily in the government but in the healthcare system, should be at the centre of new interventions, as trust has proven to be a significant determinant of effective behaviour change and management of public policy. A potential strategy could be to consider a stronger relationship that reconnects the healthcare system and the community gatekeepers. Also, HCWs should be routinely trained not just on knowledge of immunisation to prevent mis- or inaccurate information about the effectiveness of vaccines but also on general healthcare practices and ethics to shore up confidence of mothers in the healthcare system and knowledge on diseases vaccines can prevent versus those they cannot.
• The importance of seeking additional information to support mothers' vaccination decision was a novel finding. Mothers reported that the health talks provided during antenatal care (ANC) visits were a primary source of vaccination information. This finding also implies that those women who do not attend such classes are hard to reach. Mothers also mentioned other important sources of vaccination information, including non-medical sources such as relatives and peers in their communities. Therefore, further vaccination education should move beyond mothers alone, instead reaching out to entire households and communities.

Previous quantitative work using the 5C model in Nigeria has shown that not all components of the model were relevant when they were measured with the original scale. In this study, the results suggest that confidence, calculation, constraints, collective responsibility, religion, and masculinity may be relevant, while complacency was not a relevant barrier. Thus, the present results suggest that cultural adaptation may be promising and encourage a quantitative use of an extended 5C model in low- and middle-income countries (LMICs), such as those in SSA.

In conclusion, "the use of the 5C model in qualitative research can play a significant role in generating an improved understanding of caregiver's perception beyond some predefined judgments in quantitative studies and help generate very concrete ideas on how to improve on the identified barriers. The question of whether the 5C model is flexible enough to be used in SSA/LMICs more generally, since its foundations originated from the Global North, can be confirmed."