Background
Methods
Study sites
Site | Description |
---|---|
Mombasa | A major tourist area, Mombasa is located in the south east of Kenya and represents a semi urban setting. Accessibility to healthcare facilities differs on proximity to Mombasa town; Health facilities included Coast General Provincial Hospital (a KEMRI/ CDC influenza site). It is the second largest public hospital in Kenya with a bed capacity of 672. There are about 80 healthcare staff members working in child and maternal health. In 2015, the maternal clinic saw 1882 new patients and 4226 returning patients. This hospital is part of the influenza surveillance platforms. |
Nairobi | As the capital city of Kenya, Nairobi represents the urban setting. Accessibility to different types of health facilities (private/ public) is higher in Nairobi than anywhere else in the country. Health facilities included Mbagathi District Hospital which is located in Nairobi right next to KEMRI and CDC Kenya. This hospital has a bed capacity of 320. There are about 53 healthcare workers handling maternal and children issues. The average number of pregnant women seen per month at the hospital is 500. |
Marsabit | Located in Northern Kenya, it is a hard to reach and sparsely populated area. It is the most unique of all four locations as it is primarily composed of a nomadic community. Accessibility to any health care facilities is poor. Health facilities included Marsabit District Hospital which is located in the north Eastern part of Kenya. The hospital has a capacity of 86 beds. This location allowed the team to access a different population seen at the other hospitals. |
Siaya | Located in Western Kenya and close to Kisumu, Siaya represents the rural setting. Accessibility to healthcare facilities differs depending on proximity to Kisumu which is another major city in Kenya. Health facilities included Siaya County Referral Hospital which serves a large number of rural and low social economic patients. The bed capacity is 200. There are 26 health care workers within the maternal clinic that care for and see about 300 to 400 new and returning pregnant women. It is located about 72 Km from The Centre for Global Health Research at KEMRI Kisumu Field Station |
Participants
Pregnant women: pregnant women waiting for their scheduled antenatal care visits at the clinics were approached by research members and asked if they willing to participate in the study. If they were willing, they were taken to a private room/office designated by the hospital for confidential consenting and interviewing. After allowing time for consent review and answering questions, the study team recorded each interview. • Inclusion criteria: Women aged 15–40 · Women in any trimester; Patient at health facility included in the study; Be willing to converse with others in a focus group format (only for message testing phase); Able to provide informed consent (If participant is illiterate, procedures to ensure full understanding of the research and consent process will be implemented according to international and federal guidelines). • Exclusion criteria: have previously participated in this study; Those who do not or cannot provide consent; Failure to meet other inclusion criteria. • Interview Topics: Interview guide for women included discussions on the following topics: (a) have they had a checkup in the last year; (b) have they received any vaccines that they can recall; (c) if they have received vaccines, they will be asked about their understanding of the vaccines they received [e.g., do they know what the vaccine prevents against, did they get the vaccine just because their parent/doctor told them to]; (d) comfort discussing sensitive topics with their doctor and parents; (e) awareness of maternal vaccines; (f) information from peers about maternal vaccines [friends’ vaccination status, anecdotal side effects, discussions on social media, reasons to get it/not get it]; (g) discussions with parents/guardians about maternal vaccines; and (h) motivating factors to be vaccinated. | |
HCPs: providers working at the antenatal care were contacted ahead of time to arrange interviews for times that would work best for them. During this phase of data collection, HCP were on a nationwide strike. To mitigate the effects of delayed data collection, study team members organized interviews outside of clinic. • Inclusion Criteria: Currently working at the selected study sites; Current physician, nurse, nurse midwife, community health worker; Able to provide informed consent. • Exclusion Criteria: Those who do not or cannot provide consent; Failure to meet other inclusion criteria. • Interview Topics: The semi-structured interview guide for providers included discussions on the following topics: (a) proportion of patients they estimate have received or refused maternal vaccines; (b) times at which they recommend maternal vaccine; (c) practices regarding immunization history verification (e.g. immunization information system); (d) barriers or reasons for refusal cited by parents/patients; (e) perceived ability and methods used to address these barriers/refusals; (f) comfort discussing vaccine recommendations with their patients; (g) existing efforts of reminder/recall for maternal vaccinations; and (h) knowledge of Tdap vaccine effectiveness and safety. | |
Participant observation and Facility Profiles: Non-structured observation of pregnant women and HCPs were also conducted within the clinic. The research staff took detailed field notes to examine patient-administration, patient-patient, patient-provider relationships, dynamics of provider-government officials, and provider-provider, provider-patient, and provider-administration interactions within each of the selected sites. Interview notes and observations notes were used to edit the guide as needed. Notes about each facility, e.g. patient flow, vaccine storage and supply chain, etc. were also typed up over the course of interviews. |
Study protocol
Analytic approach
Results
Subtheme | Quote |
---|---|
Expressed Trust |
“When they come, they just accept what the doctor gives them because they believe the doctor is always right. They have never challenged us by asking ‘why are you giving me this vaccine and not the other one?’”
“May be sometimes they do not have that chance to say no because they look at me as their savior, the last person for them and everything I tell them they do believe is right”
“Actually, patients just come for ANC clinics and it is us, the health care providers who decide what is deemed fit for them; they do not ask for anything.”
|
Respect for autonomy |
“We believe that the client is always right. Therefore, after taking our time and proving a detailed health talk and a woman still refuses to be vaccinated, we do not force them. Clients have the right to accept of refuse medication. We honor their requests and what they believe in. we always give them a lot of information anyway.”
“Most of the mothers who come here for the vaccine know that they have to be injected. Others had not received the tetanus vaccines in their previous pregnancies so they do not see the importance of the vaccine. We explain to them the importance and tell them to go think about it and come back because we cannot force them.”
“Normally after you have done all the necessary services you will tell the mother now it is time to give you the vaccine we normally tell the mother that “I want to give you a tetanus injection” during that time she has the right to tell you if she does not want the injection or she just accepts. However, we have never had a case in which a mother declines.” |
Authoritative approach |
“We tell them what they need to have so I do not think decision-making is on their side so they just receive it.”
“I: Okay, once you make available, vaccines in your facility especially the tetanus vaccines, do you think mothers get ample time to make a timely decision whether or not to receive the vaccines in your facility?
P: They have no choice, we just tell them it is mandatory and it is good for them.”
|
Sources of trust | |
1. Education |
“Yes, they normally have time to accept because by the time they leave their homes to come to the clinic, they are very sure the doctors or the nurses or health care providers know more than they do, so they will just do what the health care ask them to do”
|
2. Altruism |
“I think it is the norm of the clients where you find that patients always feel that the doctor is the one who knows what she should receive as they believe the doctor will do the right thing.”
|
Subtheme | Quote |
---|---|
HCP Perspective | |
Impact of attitudes towards patients | “The other reason [barrier] could be maybe the way you talk to them when they come for their clinic here. For instance, if you talk to them rudely, they may not come back her.”
“I think that is attributed the service we provide. We talk to them politely. Even if the client is unhappy with you, you must find a way of working towards that. In my facility, we sometimes provide tea, snacks and water for clients.”
“The nurse kept accosting the patient about the time of coming for ANC clinic and her age. A lot of words were told to this the teenage mum that made me doubt if she would dare come back for the services though eventually got the services and ANC book provided.”
“For one is the attitude of the caregiver, the availability of the vaccines and the availability of time and staff. If we are many we will shorten the waiting time. And my attitude also if I have a poor attitude, I will discourage them but if it is good, they will encourage others to come”
|
Evolution of patient-provider relationship |
“Uptake depends on the attitude of the healthcare provider. Most mothers have issues at home and how you handle them matters a lot. When a mother walks into your clinic, they are walking to someone they believe in their heart will help them. The information you give this mother may change or break her. I believe it is all about the attitude and approach towards these clients and the education you give them.”
“These cultural practices are still there but there was a lot of force from the administration chiefs ensuring they are given by force, which should not be the case. The community should be taught then consent after understanding and receive the vaccines.”
“Some of them [providers] would be hindrances because they would not engage mothers when they are making decisions concerning vaccines dates. Some will put vaccine date to their convenience without considering the mother’s side. Those are open hindrances. There are some people who say on giving vaccines on specific working days without taking care of mothers who work from Mondays to Fridays.”
|
Patient’s desire for information |
“They will say it is new, we want to know its constituents.”
“They normally ask the importance of those vaccines, how the vaccines help them, if there is any adverse effects and what would be done in such a situation.”
“They ask on why we give the vaccines and what they prevent against. Therefore, whenever we give vaccine, we first seek their consent, give the reason for administering and talk about their importance.”
|
Effect of Time -constraints on education |
“For now, I can say they do not get enough time since I am alone, overwhelmed and take shortest time possible with them. They do not get enough time.”
“So I am the type of person who has to give the mother the information she needs. So I cannot know whether my colleague in the other room is giving that information. Sometimes I cannot blame them because you find that three benches are already full and all the women are waiting for that one person to attend them. You will find that things there are not going as intended. The education is usually not there as such. But if we had enough time... so even if there is no ample time you have to give information of the very important things which the mother has to take home from that room.”
“I think that is the only challenge because for vaccines we have everything we need like syringes and the like. If we can get additional staff, then it would help us a lot because I may take shortest time with clients since people waiting at the queue are very many thus making me rush and where I would have explained more about pregnancy may not be possible.”
“I think the most important is the human resources because if you are only one person, you become overwhelmed. Most of our clinics are usually overwhelmed especially on Thursdays and Mondays. This happens especially in the child welfare clinic where you have to take care of immunization for children and at the same time pregnant mothers. It is hectic. That is where quality is compromised because you hurry to clear the queue.”
“So you find that the nurse has a lot of work because she has to be here, she has to be in the OPD (Outpatient department) and also coordinate all the activities in the hospital. And this being a sub-county facility, she has to attend to all the visitors who come because we have the sub county officers. So the nurse will not find enough time to attend to the clients so it makes the clients to wait for long. We have to finish the other side and come to help this sides. So if you are in a position to add us one or two or more it will be good because this is a health center and it cannot be managed by two people.”
|
Pregnant women perspective | |
Importance of provider attitudes on trust as expressed by facility choice |
“I focus on the reputation of the hospital and the way the doctors treat people.”
“I look at how patients are being treated. You will come to a certain hospital after you have heard people praising it.”
“P
: The staff here are very kind and attend to us well. Their services are also good.
I
: What about [name] Hospital?
P
: Sometimes the nurses are very harsh which makes us feel uncomfortable”
“You know there are places that you can go to and you are attended to in a hurry and maybe you have a particular problem. Instead of somebody listening to you, he/she starts despising you.”
“
I
: What is it that will motivate you to go for vaccine?
P
: Pregnant mothers are sometimes turned away from hospitals when they go to deliver if they never attended the antenatal clinic.”
|
Accessibility |
“Well actually the distance from our home to this place is quite long, but I have no choice but to come here. Clinic services for pregnant women are available only in a large facility like this and not in small health centers and dispensaries like the one in our location.”
I:“In case you become sick, and you want to go to the hospital, what can you put into consideration?
P
: When I become sick and I want to go to the hospital?
I
: Yes.
P
: I must have means of transport to the hospital. (Laughs).”
“However, this side you must be sick is when you come or when your day for clinic reaches is when you come, a times you are sick and the place is far you will just be force to persevere.”
“I just go to the hospital that is close to me.”
“Yes, this general hospital is closer to me than the others are.”
“I
: Okay, and what do you do if you get sick?
P
: I go to the hospital
I
: Which hospital?
P
: Any that is close to me”
“You go to the nearest hospital when you are sick.”
“
I
: why this one? What attracts you here?
P
: It is near where I stay”
|
Subtheme | Quote |
---|---|
HCP Perspective | |
Effects of myths and misconceptions (“Rumor mill’) |
“We recently had a challenge with polio and other vaccines that were being said to bring infertility. Those who do not get a chance to talk to a healthcare professional to enlighten them about these myths end up believing what they are told out there. The public sector has these challenges.”
“For example, sometimes back, there was a serious debate between the ministry of health and Catholic church. The church was against the tetanus toxoid. The catholic church argued that the vaccine was meant to sterilize female populations. The issue was all over the internet and social applications. I think vaccination efforts did not reach their targets. There are some who also complicated the issue justly to scare more people away from vaccination.”
|
Education as a tool for demand creation and reinforcing/ building trust |
“When communicating to them we need to tell them about the importance of vaccines and insist for them to receive. If you do not tell them about the importance, then they will not take. As you know that the patients normally believe in doctors and they will do whatever the health care provider suggest to them to do.”
“We should have somebody at the triage, one in the child welfare clinic, one in the ANC clinic, one in the family planning clinic and one in the PMTCT. This would help us give mothers time to ask questions and also give as time to address them. This will also make the mothers to be comfortable with us since I will not be rushing through but will have adequate time to give the mother’s health information. Pregnant mothers need a lot of information and especially first time mothers who could be having wrong or outdated information”
“There are pamphlets with pictorials about the effects of tetanus infection. When we show women such pictures, they understand the importance of tetanus vaccine and accept vaccination. You realize that TT uptake is increased. They are confident with what we tell them and we are also confident that their attitude is positive. This is evident in the fact that they come in numbers for the vaccines. In some cases, they come from other hospitals. They trust us.”
“The first thing, which I appreciate about health information given to the mothers; is that at least they know that there is an antigen which they should be given and they appreciate about that antigen. Secondly, they know the importance of attending the ANC clinic because if you ask them why they always come to the clinic, they will tell you that “I come because I need to be given tetanus” so basically, the message you give them has a positive impact.”
“Barriers. Mostly because most of the issues that normally come up are always myths, we try to debunk them by trying to tell them the facts. Like somebody believing that when they are pregnant they can’t get injected, you talk to them, you tell them the importance and we also expose them to know the side effects though in most cases the side effects are always very minor and I have never met an adverse reaction with the vaccines. So we always try to talk to them. We let them know the facts so that they make an informed decision. Some come when they have bad opinion about vaccines but they end up getting it, having been given the facts.”
“Basically, it is the health information. We give them a group health talk outside then when they come in, we have one on one health talk. However short it is we make sure we tell them the importance. By the way, I have realized they know the importance of tetanus. Once we give them the information on the importance of the vaccine so we do not expect refusals.”
|
Community buy-in |
“More publicity. These can be done by women who have received vaccination telling fellow women, pregnant and non-pregnant alike about the importance of vaccines. Government officials like chiefs and village elders can also play their part by organizing barazas-(Gatherings/meetings organized by the local chiefs to address issues) for all women where they will be educated on vaccines.”
“They should also have the information because one mother will tell another and that is how information flows.”
“The moment they know what we are doing, they become our ambassadors in most cases. They take that message home. When you do something right to one patient, you will help like five of them because when she goes out there, most of them share their experiences.”
|
Pregnant women perspective | |
Effects of myths and misconceptions |
“I:
Why do other people refuse vaccines?
P:
Others just take it lightly, others because of religion and others think it is wasting time.”
“I:
Have you ever refused vaccine for yourself before?
P:
Yes. There was one that brought lots disagreements. You know I am a Catholic … It was also in church but when we saw our leaders arguing with the government saying the vaccine is not good that it has other things. I rejected that one. By that time if you went to the clinic you could be asked to be given the vaccine but I refused.
|
Importance of education on vaccine acceptance |
“Yes, the information on children’s vaccines was helpful. When the healthcare providers came administering the measles vaccine, a measles outbreak had just occurred. The healthcare providers informed us that those who will get the vaccine before contracting measles will be safe. And because of this information, even those who had never been vaccinated before came for vaccination.”
“Why I received the tetanus vaccine was, it was well publicized, the information that came with it was okay, those people who were also giving it out, I believe they were professionals because they also had tags. Before they give you the vaccine, they had to explain what would also be compared with the information we had before; to me that was okay, I did not even need a second thought about it, yes.”
“Mothers should be educated on vaccines first and then they can choose. As I told you earlier, some mothers refuse vaccines because of some misconceptions they hear about vaccines. There was a time everyone thought that polio vaccines would kill a child. I do not think the government can kill all the children in Kenya, I believe there have a conscious too.”
“They said that children will be prevented from serious physical handicaps and polio. Since I do not have more knowledge than doctors, I accept to have my kids vaccinated.”
“I
: Let us say she refuses and the child happens to be infected by the disease that would have been prevented and remember the child has no capacity to take her/himself to the facility for the services, so what do you suggest to be done to such a parent?
P
: Just give her good pieces of advice.”
|
Desire for health education |
“I come here because of the services they provide but mostly I like the guidance and counseling they provide.”
“AMREF together with the nurses usually go round the villages to vaccinate the children so I ask them about it that is where I learnt from. I have to ask because I will find myself in that situation where my child has to be vaccinated so I need to know.”
“I think you should put more advertisements on radio and television. There should also be caregivers to teach us when we come here in the morning. But you find that when you come to the clinic, you might sit at the reception for even an hour without anybody attending to you. When they finally attend to you, you just go home. Ever since I started coming here, we have only been educated once. Maybe it is me who comes early and they do it later.”
“For example, I went to a private hospital but I was not given any vaccine or advice as a pregnant woman. I was also not asked any question as a pregnant woman. They only tested me and filled the form and by that time I was in great pain. That is all they did. So I thought that if I come to Mbagathi Hospitals, I will get vaccinated and get advised. Like today I have been advised to start preparing for the delivery of my baby. I have been told to have a razor blade, string and money. I have received advised which I would not have received in private hospital. I have also been told that I need to eat well as a pregnant mother and to also use folic tablets for me to have enough blood in the body. I would not have received such advice in a private clinic.”
“
I
: Between government hospitals and private hospitals, where would you prefer to be vaccinated?
P
: Government hospitals because they educate a lot on vaccines.”
|
Fear of reproach |
“There are some doctors that when you ask them questions, they will also ask you, if you came to be treated or for questions; it becomes difficult to interact with such ones.”
|
Time constraints |
“I do not ask because I find many women on the queue. You do not have the time to ask why do you so you just agree to be injected so that you go home.”
|
Subtheme | Quote |
---|---|
Explicit trust |
“I
: Why would you trust the doctor?
P
: If there could be no doctors I could not be even alive. They have really helped me.”
“Since I am sick, I will trust no one but the doctor, he will screen me and then tell me what the problem is.”
“You see you can discuss with people from home but they are not doctors, they will listen to your issues and at long last refer you to go and see the doctor because they have no knowledge on the same. At the hospital, the doctor will examine, test and know the cause of the problem while at home people will tell you it is just malaria; I think that seeing the doctor is the best thing.”
|
Direct impact of trust on acceptance |
“I will comfortably receive vaccines here at the hospital because it has the right personnel. I will not take it anywhere else where there are no experts.”
“I believe that anyone who gives me vaccines knows why he is doing that; I believe he/she has gone to school and understands this issue better than I, and I have no reason to refuse as long as the vaccine does not kill me, and as long as my health improves.”
“
I
: why wouldn’t you refuse to receive vaccines?
P
: This is because it is important to our body and especially if it’s given by healthcare providers who are experts and informed then I cannot refuse.”
“I will accept because it is recommended by the doctor since that is their profession hence they have knowledge as to why they bring that new vaccine.”
“Some people even think if they are vaccinated they would come impotent like in men even women would not give birth like the case of tetanus, what other women used to say is that women have born a lot of children in Kenya, so that vaccine is a way of birth control that was going around which I also heard but I said if it is so that is what the government is planning which I don’t think is true, so me I just went ahead and received. It has not stopped me from conceiving, yes.”
|
Reasons for trust 1. Respect for provider’s education 2. Government authority 3. Belief in provider’s altruistic motives |
“I trust them because these are people who have knowledge in that line, it is something they have studied, yes, they have been tested on that so they stand to convince me that I can rely on them.”
“I will accept because it is recommended by the doctor since that is their profession hence they have knowledge as to why they bring that new vaccine.”
“I will rank the hospital as the first, because the information you get from the doctor has no doubt since the doctor has the knowledge.”
“I will still admit because it is a government command”
“Yes, I do believe that vaccines are safe because the government cannot bring something that will harm us.”
“So I knew it was something that was initiated by the government so I did not see the need to debate it that is why I went ahead and took it, yes.”
“Because I know that when the Community Health Workers comes they come with the doctors and secondly when I’m in the hospital I trust all of them because I have never seen a doctor without a tag and that will prove that what they are doing is what has is authorized by the government.” “However, you cannot refuse yet it has been rolled out by the government and doctors. A doctor cannot prescribe harmful drugs, unless a quack.”
“I know the doctor is the one who treats people so if he gives me the vaccine I know it’s a correct thing, because the doctor cannot wish to harm anyone.”
“I
: You have said you trust the doctor why do you trust the doctor?
P
: Because they have already devoted to help people.”
|
Preference for public hospitals |
P:
I go to government hospitals.
I:
Why?
P:
Even if you do not get medicine, the medicine they prescribe is good because they are not looking for money unlike private centers where they tell you medicine are original and you are left wondering whether there are fake and original medicine. I worry about that.
P
:You know everybody has their own decision but for me I decided all my medical advice and services I will be getting from a public hospital and that is why I am here.
I
: So what is good with this public hospital that is not in the private hospitals?
P
: In public hospitals you are sure, somebody will not cook. You are sure of services and it is not business so if you have a particular problem you will be told that you have this particular problem, there is no exaggeration or undermining that is why I choose public hospitals.
|
Health care providers’ perspective
“They have no choice, we just tell them it is mandatory and it is good for them.”
VS.
In both examples, providers explicitly or implicitly expressed perceived trust from their patients. However, the first provider had a more paternalistic view while the latter expressed the need to inform their patients. Ultimately, regardless of their personal belief systems, all providers recognized the amount of power this trust bestowed upon them and believed patients would not typically refuse to adhere to their recommendations (Table 3).“I think, when women come to the health care provider they have trust in them. Since they trust us, they will also trust what we tell them. It is now our work as the health care providers to give convenient information to these women so that they can go back to their homes satisfied.”
Nowadays, people do not harass mothers like in the previous years … In the past, people used to be blasted by the nurses or whoever was giving the services whenever they asked questions. Those days are long gone. It is always good to ask why you are being injected .
“Maybe when a health care provider is in a hurry or is being overworked. You may find a long queue at the ANC waiting for vaccination. The nurse there may not have time to discuss much with every client about the vaccines. Sometimes they issue orders for the mothers to queue and get vaccinated. These are situation which may happen when there are several mothers at the clinic. This can cripple vaccine uptake since there is no time for explanations.”
“But with continuous education given, the posters, you find that the number that come to access vaccination is high. For example, if you forget to give they will ask you for the vaccine.”
“They always appreciate as long as the information that is being given to them is from somebody from a medical profession and whom [they] trust.”
Pregnant Women’s perspective
1. Expressed patient trust
It is us who need it, and we don’t know why we need it, so there is no way we can refuse. In addition, you cannot dispute what a doctor tells you, especially on something that he has taken years to train for. Even if they inject you with poisons or any other substance other than the vaccine, you wouldn’t know and you won’t have any say.”
When asked why they trusted HCPs, most pregnant women replied that they trusted providers because 1) providers are learned about health and are the only ones who can decipher their illnesses and treat them accordingly, 2) providers have institutional authority from the government to guard their health and 3) providers are healers and caregivers with honest motives (Table 6). Most notably, in some of the cases where patients showed hesitancy towards vaccines, patient trust in the government, superseded that mistrust (Table 6).“I believe it is safe if it is from health centers but not out there because you may not know who sent them and their motives. I would rather come to the hospital to confirm if there is a vaccine being given” .
2. Provider attitudes towards patients (respect and approachability)
It is however important to note that provider attitudes were mostly considered as a factor in vaccine decisions by participants living in urban areas where there is an abundance of facilities available. Most participants living in rural areas often reported having little choice in where to go and considered distance and cost much more than they did provider attitudes (Table 4).“Personally I would not have come back here if it were not for my condition because of my first experience here. Because when you come to the clinic, you expect to find friendly people who are ready to help you. But if you come and find somebody who is arrogant, one who has I do not care attitude and it is like you are bothering them, I will prefer to go somewhere else where I will find somebody who will understand my condition.”
3. Patient health education
“I come here because of the services they provide but mostly I like the guidance and counseling they provide.”
“Even if it were you, you would be scared. We believe that if you are a know-it-all, they may even harm you. It is like telling the doctor ‘you did this and it is not done like that.’ You are sure that is not how it is done but because he/she wants to show you that he/she is there for that job and knows more than you do people say that he/she can harm you because you do not know what you are being injected with.”