Using photovoice methodology to uncover individual-level, health systems, and contextual barriers to uptake of second dose of measles containing vaccine in Western Area Urban, Sierra Leone, 2020

Abstract

Background: Vaccination coverage for the second dose of the measles-containing vaccine (MCV2) among children has remained stagnant in Sierra Leone at nearly 67% since its introduction in 2015. Identifying community-specific barriers faced by caregivers in accessing MCV2 services for their children and by health workers in delivering MCV2 is key to informing strategies to improve vaccination coverage.

Methods: We used Photovoice, a participatory method using photographs and narratives to understand community barriers to MCV2 uptake from March- September 2020. Six female and five male caregivers of MCV2-eligible children (15-24 months of age), and six health care workers (HCWs) in Freetown, Sierra Leone participated. After having an orientation to photovoice, they photographed barriers related to general immunization and MCV2 uptake in their community. This was followed by facilitated discussions where participants elaborated on the barriers captured in the photos. Transcripts from the six immunization-related discussions were analyzed to deduce themes through open-ended coding. A photo exhibition was held for participants to discuss the barriers and suggested solutions with decision-makers, such as the ministry of health.

Results: We identified and categorized nine themes into three groups: 1) individual or caregiver level barriers (e.g., caregivers' lack of knowledge on MCV2, concerns about vaccine side effects, and gender-related barriers); 2) health system barriers, such as HCWs' focus on children below one year and usage of old child health cards; and 3) contextual barriers, such as poverty, poor infrastructure, and the COVID-19 pandemic. Participants suggested the decision-makers to enhance community engagement with caregivers and HCW capacity including, increasing accountability of their work using performance-based approaches, among different strategies to improve MCV2 uptake.

Conclusion: Photovoice can provide nuanced understanding of community issues affecting MCV2. As a methodology, it should be integrated in broader intervention planning activities to facilitate the translation of community-suggested strategies into action.

Keywords: Community participation; Immunization barriers; MCV2; Photovoice; SHOWeD.

Fig. 1

A man holding a dead child. “As you can see from the photo, you will notice that the man is standing [holding] a dead child…This child is said to have died as a result of the uptake of the MCV2. Just after when they came from the hospital for the MCV2 vaccine, the child started vomiting and her mother called some [of] her neighbors to help know what to do. As they were trying to rush with child to the hospital, she died on the way going. During the burial process, other women where in full attendance and [were] made to understand that the child died as a result of the uptake of the MCV2. So, it was a lesson learnt from the community people that, the MCV2 is a killer vaccine and that they should not go for it when the time comes.” (Father, prompt 3, photo caption).

Fig. 2

Lack of proper parental care. “This picture shows a mother who is not too responsible when it comes to childcare. She was supposed to take her baby to the hospital for MCV 2 but didn’t; she decided to come with her baby when the baby fall ill. We decided to follow up, on the immunization record of the baby as that is what we do since we are not going out on outreach. We realized that the baby defaulted in the uptake of the MCV2 and even the under-five card was missing.” (HCW, prompt 3, photo caption).

Fig. 3

Lack of attention. “This is a nurse who is in charge of triaging patients. Instead of her doing her duty she is busy playing with her phone delaying patients and this is very annoying. It weighs some parents down and aids them in escaping from subsequent vaccines”. (Mother, prompt 2, photo caption).

Fig. 4

Hawker. “This is a mother who sells things by hawking and as you can see from the picture, she is always having her baby on her back. She is always too busy finding money to take care of the family which she takes so important that there is little or no time in taking her baby to the hospital for vaccines.” (Mother, prompt 2, photo caption).

Fig. 5

Under-five card. “Some hospital still gives out the old card which shows that measles [vaccine] should be given at nine month[s] so because of this most mothers with this card are not [offered] measle 2 dose.” (Mother, prompt 3, photo caption).

Fig. 6

Queue to take immunization. “This is a picture showing a long line filled with mothers and their children that have been on queue for some hours waiting for vaccines. This is time-consuming, and it creates a bad impact to mothers of not going to the hospital.” (Mother, prompt 2, photo caption).

Fig. 7

Free health care. “Free health care was designed to help parents who are poor in caring for their children until they reach the age of five years, and it is a very good idea. But its design has nothing to do with the health workers providing the services to the children. Most of the health care workers who are providing services to these children are not on payroll and hence some will come to work when…they feel [like it]. Sometimes a lot of patients will come for immunization and only few staff will turn out on that day. This will discourage the mothers or caregivers and has given a fixed notion that health workers especially the nurses are [not] working which is not the case. Some of us are really committed to our jobs.” (HCW, prompt 3, photo caption).

Fig. 8

Flooding in the community. “Flooding in our community is one of the barriers in the uptake of MCV2. We usually have flooding every year that cause destruction on the live[s] and property of the community people. The woman is busy relocating her children and properties. It is during this process that they lost their immunization cards. After the whole flooding, she was afraid to take her child to the hospital for MCV2 because of the lost immunization card and also the demand the nurses will make as a result of not having her child[‘s] immunization card” (father, prompt 3, photo caption).

Fig. 9

Times of COVID-19. “During the outbreak of any epidemic or pandemic as the one we are currently experiencing, majority of the mothers especially those with children under the age of five will stop visiting the hospital for their health care needs and not just immunization. Because of the rigorous procedure they will have to go through at the facility, majority will prefer to stay at home as they think visiting the health [care facility] will make them infected. [People think that] health workers are those responsible for [COVID-19’s] spread, and some even think they come with illnesses just for them to make money” (HCW, prompt 2, photo caption).