Barriers and facilitators to timely birth-dose vaccines in Kinshasa Province, the DRC: a qualitative study

Abstract

Background National vaccine policies across the world have successfully improved infant vaccine coverage, but birth-dose (BD) vaccine coverage remains low. Countries such as the Democratic Republic of the Congo (DRC) aim to include the hepatitis B birth-dose (HepB-BD) vaccine in their national immunization schedule. HepB-BD’s short window for administration – within 24 hours of delivery to prevent mother-to-child transmission – adds to the complexity of streamlined and timely BD vaccines. This study aims to identify and understand barriers and facilitators to timely delivery of BD vaccine in Kinshasa Province, DRC, through individuals’ accounts with different perspectives on the uptake of the BD vaccine in preparation for its future roll-out. Methods We conducted semi-structured interviews in seven health facilities across Kinshasa Province from June to July 2021. We purposefully sampled health facilities from the provinces’ five most prominent facility types—private, public, Catholic, Protestant, and not-for-profit. We interviewed decision-makers and/or providers from various levels of the health care continuum, including midwives, immunization staff, heads of maternity and immunizations, and vaccine officials at the health zone and the Programme Elargi de Vaccination (PEV) to understand administrative barriers to BD vaccines. We also conducted interviews with expectant mothers to elicit knowledge and perceptions about infant vaccines. Results We interviewed 30 participants (16 informants and 14 expectant mothers). Interviewees were recruited from 7 health facilities, 2 health zones, and PEV. Data analysis was guided by the Consolidated Framework for Implementation Research (CFIR). Our analysis identified 13 constructs (2-3 per domain) related to the success of timely and streamlined BD vaccines. We found significant barriers within and across each domain; most notably, the multi-dose vials of existing BD vaccines determining when facility staff could vaccinate newborns, often resulting in untimely vaccinations; logistical concerns with regular national vaccine stockouts and ability to store vaccines; complex and unsynchronized vaccine fees across facilities; inadequate communication across delivery and vaccination wards; and limited and at times incorrect understanding of vaccines among mothers and other community members. Conclusions Using the CFIR framework, this study integrated perspectives from facility informants and expectant mothers to inform national policy and implementation of the HepB-BD in DRC. These stakeholder-driven findings should guide the streamlining of timely BD vaccinations upon HepB-BD implementation.

Determinants of the uptake of childhood immunization in Kinshasa Province, the DRC: ordered logit regression analyses to assess timely infant vaccines administered at birth and six-weeks of age.

“…Higher general readiness scores and attending a religiously a liated facility were independently associated with both BCG and HepB3 timely uptake, a nding that aligns with previous studies highlighting vaccine storage and stockout challenges in the DRC (13,21). In prior work, lower general facility readiness scores have been reported as barriers to timely immunization (22).…”

“…In contrast, visits to private, non-religious facilities were positively associated with timely uptake of both BCG and HepB3 than religious facilities. Previous studies on immunization uptake in SSA have cited a facility's religious a liation driving a mother's choice to seek care there (13). In terms of private facilities, studies show that mothers visiting private facilities tend to be of higher income levels (23), a factor that was positively associated with timely vaccine uptake and may explain our ndings.…”

“…Mothers primarily receive healthcare information from two sources: health workers during ANC visits, and their families and communities. Previous studies have shown that knowledge about HBV risk and the vaccines' protection is low among Congolese individuals (13,29), with one study nding a basic knowledge of HBV among only 33.2% of healthcare workers (29) and another nding that only 31.2% (87/280) of pregnant knew how HBV was transmitted (30). To increase a mother's knowledge, initiatives to disseminate vaccine knowledge could be targeted to the mother's two primary sources of information, the facilities during ANC visits and their communities.…”

“…A study in Kinshasa Province across health facilities highlighted signi cant challenges to the timely delivery of existing BD vaccines to newborns. Major determinants of the timely uptake of BCG and OPV0 included facility-level administration logistics, vaccine stockouts, and vaccine wariness and hesitation (13). The current DRC national immunization schedule de nes timely delivery of BCG and OPV0 BD vaccines as within the rst seven days of life.…”

Drivers of Early Childhood Vaccination Success in Nepal, Senegal, and Zambia: A Multiple Case Study Analysis Using the Consolidated Framework of Implementation Research

“…Some respondents, mostly at regional or local levels, believed that training was missing, not frequent enough, or reached various levels of implementation at national to less local regions. Several studies have demonstrated the impact of training on delivery of immunization programs [15,28]. Some challenges to vaccination at the community level included language, geography, education or poverty status.…”