Identifying Interventions to Reduce Missed Opportunities for Vaccination (MOV) in a conflict setting, Tigray, from a Healthcare Worker Perspective, 2023

**Note: This is a hypothetical study. This was written in May 2022 for a MSc course at LSHTM and has not been updated since**

Abstract

A horrific civil conflict in Tigray has just ended, which left millions of people dead, displaced, and without basic access to healthcare, especially life-saving vaccinations. The population is vulnerable to extreme risk of outbreaks, with only 2/10 children receiving vaccinations. Missed Opportunities to Vaccinate (MOV) protocol will be used to assess how vaccine equity can be achieved, even in areas of conflict and lack of access to care due to a broken or fragile health system. This will help to inform vaccination equity in hard-to-reach communities worldwide and contribute to closing the gap on MOV and zero-dose children.

Seeking to answer three questions: How many opportunities for vaccination are missed? Why are they missed? What can be altered to capture more opportunities for vaccination? Aiming to provide three priority interventions to close the vaccination equity gap which could provide insights for communities facing similar circumstances.

Study will take place over eight months between January and August of 2023. Qualitative aspects of Missed Opportunities for Vaccination (MOV) protocol include Focus Group Discussions (FGD) with selected healthcare workers (HCWs) in the Tigray region and In-Depth Interviews (IDI), and dissemination of ideas and interventions alongside the Ethiopia MOH and EPHI and the zero dose community at large.

Background

Tigray, one of ten regions in Ethiopia, is host to 7.3 million people as of 2021. The region has been devastated by conflict between local Tigrayan liberation defenses (TPLF and TDF) and the national Ethiopian government-allied forces (EDNF). This conflict, on top of killing over 500,000 people and displacing over 2.3 million people, has shattered Tigray’s health system. Progress has been set back by decades. According to the UN Human Rights Commission, over 70% of health centers are non-functional with only 40 out of 224 currently providing services. Health care centers and workers have been specifically targeted throughout the conflict (1–2). Within this wake of destruction, comes missed vaccinations and an increased risk of outbreaks, especially within migrant and displaced populations (3). The UN is reporting that polio vaccinations are needed for 887k children and measles vaccines for 790k children (2). This doesn’t even consider the effects of the COVID-19 pandemic on the population and health system at large in the region (1). Outbreak risk is significant and policy action and intervention are needed to ensure that all opportunities for vaccination are seized.

Tigray was once home to one of Ethiopia’s best healthcare systems (1). Where there was once hope and progress, there is now an effort to rebuild and regain what was lost. To do this in such a fragile system, no child should be left behind. Ethiopia, and especially Tigray, is a young population with 14.5% of the population being under 5 years old. Vaccine-preventable diseases are still a major cause of under-five childhood mortality, which has only worsened since the conflict (1, 4). This mortality and morbidity burden can be lifted through increasing vaccine coverage. This is partially why Ethiopia was named a Global Alliance for Vaccine and Immunization (Gavi) focus country, as it has one of the lowest coverage rates across all low- and middle-income countries (LMICs) (5). With the Gavi 5.0 initiative and Immunization Agenda (IA2030) both making Ethiopia a target for increasing coverage, resources will be made available to ensure that gaps are filled across the region (6–7). According to the DHS Program, basic vaccination coverage for children 12–23 months includes one dose of BCG, three doses of DPT-HepB-Hib pentavalent, three doses of polio (OPV), and one dose of measles. Full vaccination of children 12–23 months includes basic vaccinations plus three doses of pneumococcal conjugate (PCV3) and two doses of rotavirus (8). Please see the Ethiopia vaccine schedule for reference (Table 1) (8).

As of 2019, 4 out of 10 children have received all basic vaccinations or 43%. Close to 2 in 10 or 19% have not received any vaccinations at all (8). This is before the conflict began. Ethiopia has .35 HCW/1000 people (9). In Tigray, as of 2019, there were 789 Health Extension Workers (HEW) in Tigray or 15/100,000 (6,790 people per one healthcare worker). This number is likely lower now after the conflict and deliberate targeting of healthcare centers and workers (2, 10).

Many studies have been done to assess un- or under vaccination of children in LMICs, which will be used to inform the study (4, 11–16). Other studies have focused on the caregiver side of childhood vaccination, with findings including vaccination coverage is strongly associated with better wealth status, better education of caregivers, living in urban areas, and living in male-headed households (4, 8). However, several of these are quantitative and not in conflict settings. This study would serve as an opportunity to see where MOV occurs in populations with a high degree of movement and what sort of interventions would best serve a community facing these particularly dire circumstances. Qualitative assessments about where there are missed opportunities to vaccinate (MOV) from an HCW perspective, as they bridge the gap from the health system to the consumer, must be made to add nuance to the discussion. This will ensure interventions are tailored to these communities and reach all children to ease outbreak risk and make sure no one is left behind (6–7).

Aims & Objectives

This study aims to identify barriers and interventions for a targeted program to improve vaccination coverage among children 0–23 months old in underserved Tigrayan communities. Post-conflict vaccination equity and missed opportunity require several questions to be asked and answered by using both quantitative and qualitative methods. Qualitative research methods provide a deeper, more nuanced look at MOV that can lead to a customized alteration of protocols, training, and policies. Tailored interventions can be scaled to close the gap on zero-dose children and sharing the outcomes can create a better understanding of vaccination equity coverage in similar settings around the world (17).

The main questions and corresponding aims are:

1. How many opportunities for vaccination are missed when children are seen?

To evaluate the magnitude of missed opportunities for vaccination in a post-conflict setting like Tigray.

2. Why are these opportunities missed?

To understand the underlying causes of missed opportunities of the Tigray region.

3. What can be altered?

To explore what can be altered to reduce missed opportunities, therefore limiting the number of un- or under-vaccinated children (17).

Research Design & Methods

To conduct this study, the established protocol laid out by the WHO for the assessment of missed opportunities for vaccination will be utilized (17). The methods will be set to answer each question and the details of each method are explained in detail and will be followed up by a brainstorming session, thematic analysis, and comparison to other studies done in other conflict settings (17).

Defining each step, and the advantages and limitations of each method will help to better understand what interventions can be created due to our knowledge/understanding limitations. To first define MOV is an important step in setting boundaries around what this study can accomplish. MOV in this study is defined as any contact with health services by a birth-23-month-old child who is eligible for vaccination, therefore un or under-vaccinated or not up-to-date, and free on contraindications (perceived symptoms or conditions) which does not result in the child receiving all the vaccinations or which they are eligible (17–19).

MOV includes:

1. Failure or inability of health providers to screen patients for eligibility

2. Perceived contraindications — symptoms or conditions — to vaccination on the part of providers and parents

3. Vaccine shortages

4. Rigid clinic schedule that separates curative services from vaccination areas

5. Parental or community resistance to immunizations (18).

6. Not in the MOV, but due to recent findings — failure to open a vial due to large vial size (20).

Methods:

1 & 2 — How many opportunities for vaccination are missed when children are seen? Why are these opportunities missed?

Exit interview / Vaccination Data from caregivers and healthcare workers

HCW Focus Group Discussions (FGD)

Health Administrator / Senior Staff In-Depth Interviews (IDI)

3. What can be altered?

HCW FGD

IDI

Brainstorming Session with a working group (17)

Exit Interviews / Vaccination Data

This is the quantitative information that will help to guide where the qualitative methods go and why. However, due to the conflict just ending in Tigray, the exit interviews will not be conducted and will be replaced with compiling data from the Ethiopia Mini Demographic and Health survey 2019, Ethiopia National Expanded Program on Immunization 2016–2020, WHO Immunization data, and the EPHI database (8, 21–23). This data includes sociodemographic data, vaccination cards, mother’s report, and health facility records that were collected for 1026 children 12–23 months old for BCG, DTP3-HebB-Hib, 3-dose polio, 1-dose measles (MCV1), 3-dose PCV3, and 2-dose Rotavirus. Data from 1028 children 24–35 months were collected for MCV2, as well as vaccination coverage for each antigen in recent years to help understand how rates have dropped (8, 21–24). The data will be cleaned, anonymized if needed, and analyzed for trends with an additional stratification for gender (24).

Focus Group Discussions (FGD)

A focus group is a purposefully planned discussion designed to obtain perceptions on a defined set of aims in a permissive, non-threatening environment (25). There are many functions of FGDs and the main ones utilized here are outlined below.

Functions:

1. Learnings on how participants talk about MOV, the strength of their feelings related to MOV, as well as what they see as priorities

2. Explore new research hypotheses and testing related to MOV and vaccination equity

3. Diagnosing the potential problems with existing structures, policies, and protocols and not yet diagnosed problems

4. Obtaining more nuanced background information related to MOV and vaccination equity

5. Interpreting previously obtained quantitative vaccination data

MOV protocol will be used as guidance and will help to structure the FGD (17). A local Tigrayan social research assistant will be hired and trained to help facilitate the focus group to navigate in a culturally appropriate and respectful way, as well as to ensure the comfortability of the participants to share their genuine opinions, thoughts, and critiques. There are many advantages of using a focus group that pertain to these research questions. It will allow for a more natural setting of discussion between HCW around issues they have in vaccine delivery, and they will be able to learn from one another as well as hopefully go deep and unearth issues that wouldn’t normally arise in a more general survey or one-on-one interview. This will allow for more nuance and the realities within their work vs what the data says. The FGD will help to gain a sense of what is going right and wrong, what are the real hindrances, what seems impossible from day to day, what possible solutions are, and what can be scaled. A focus group will allow for long-form discussion and a better flow of information, even if it does stray away from the topic from time to time. Exploration of topics is okay as the aim is to find more areas to explore and more outlets for interventions for MOV (17, 25–26). Limitations within the focus group are that it could go down a path that is not helpful to this study and therefore will not lead to quality data and outputs, but the structure should help in curtailing any tangential paths.

A total of four FGD will be held with 6–12 HCW in each session that is close in distance to the healthcare centers/areas they work in, but not too close as the discussion should remain confidential. The participants will be selected with varying levels of experience, age, and gender if possible. Each session will be scheduled for 90 minutes max, and the research assistant will be facilitating and taking notes, as well as I to capture reactions and quotations, but each session will be recorded as well. Specific semi-structured scripts will be written up two weeks before the first session (17).

The sessions will be structured as follows:

Introduction — Individual introductions of researchers and participants, ethics and consent forms (due to recording, confidentiality, and anonymity)

Opening Questions — Get the conversation started and make the participants feel comfortable

Key Questions — The questions the study aims to go deep on, including hindrances and thoughts for solutions

Closing — Summary, thanking participants, positive thoughts going forward on how the participants are contributing to this important cause to reduce MOV (17, 25).

In-Depth Interviews (IDI)

In-Depth Interviews are semi-structured one-on-one interviews that provide qualitative data geared toward the research questions of interest. A semi-structured interview has a general agenda of topics to discuss but leaves room for the interview to explore how they answer and in what depth (25). These interviews have their advantages and limitations. It can produce data about interviewees’ beliefs, perceptions, experiences, classifications, and accounts of the world, but cannot be a direct representation of the world, only the interviewee’s perception of the world (25). All to say is that this interview data is not objective, but subjective and shaped by the individual’s accounts if done correctly can be invaluable to a qualitative research study. In each interview, the professional position of the interviewee will need to be considered as some will be quite powerful and speaking on behalf of their organization, therefore, the framing of the questions will be significant in gaining the answers that will be most helpful in determining outputs (25).

The questions for these interviews will be customized to each interviewee with some overlapping questions to correlate answers. Once again, the MOV protocol will be used as guidance (17). They will be written and facilitated in tandem with the research assistant to ensure appropriate cultural and political language is used. The interviews will be recorded and therefore consent will be required. Since it will be recorded, this will be noted as a public interview, even though the recording will not be shared. This may affect the participant’s answers (25).

The study will aim to interview a range of professionals working in health in Ethiopia as well as Tigray. Some possible options have been identified, but a longer list will need to be done, especially with such a volatile environment. Not all candidates may be willing to participate, some may agree and then back out, or may not be available when research is conducted. The candidates need to have a deep understanding of vaccination in Ethiopia and Tigray, ideally having a systems perspective with experience working in the field. Below are possible candidates who would contribute the most to the study.

Thematic analysis / Policy Analysis

After all FGDs and IDIs are complete, all notes will be collated and preliminary analysis will be done to identify major themes and results. The results of the FGDs will highlight major themes discussed as well as any illustrative quotes or conversations, as well as any major barriers and interventions, explored. And the results of the IDIs will highlight key hindrances and potential solutions.

After thematic analysis will compare to studies in other conflict regions to generate recommendations for the MOH and publish findings on how the MOH can better reach under and unvaccinated children 12–23 months. A gender lens will be applied within the FGD and IDI and any quantitative data will be stratified by gender to see if any trends appear in the region. This will be done according to Gates Foundation protocol in partnership with the GenderTech team at Standford University and guidance from the IA2030 Protocol (24). The aim is for a gender-specific approach, but know that it may only be possible to achieve a gender-sensitive assessment due to limitations of quantitative data. Gender transformation, given the circumstances of conflict, will likely not be possible here, but an analysis of how it could be improved for future studies will be included in the outputs. Approach 8 (Implement gender-responsive immunization services in emergency settings) and 9 (Apply a gender lends to research and innovation) will be most applicable here and IA2030 Why Gender Matters will guide this analysis (24).

Existing policy analysis will also be conducted to garner an understanding of what needs to be altered at that level as well as to do a comparison of other regional/national policies to understand how interventions can be scaled and implemented in other settings (17).

Brainstorming Session

After key themes are identified, the MOV protocol requires a brainstorming session on proposed interventions and to develop a framework for implementation. This will be done alongside the Ethiopia EPHI, Ethiopia MOH leadership, and any partner organizations that will be helping to implement these suggested interventions (17). This session will be carried out over 1–2 days in small working groups and the outcome will be a draft action plan to reduce missed opportunities with listed priorities over the next 6–12 months. The framework, roles, and responsibilities for implementation will be drafted shortly thereafter and disseminated along with a monitoring and evaluation plan (17).

Ethics

Acknowledgments of where the researchers work and how the study is funded will be outright. The primary investigator works at the Bill and Melinda Gates Foundation and studies at the London School of Hygiene and Tropical Medicine. Permissions for research need to be obtained and approved by BMGF, LSHTM, and the EPHI-IRB (27). All permissions will be obtained before proceeding with the study. The quantitative data obtained will be permitted via the MOH and EPHI, and will be anonymized before analysis is performed.

Consent forms from all FGDs and IDIs will be signed and an ethics brief about how and why the research is being done will be given to all participants before signature.

Obtain permission from LSHTM & Ethiopia IRB. Since all FGDs and IDIs will be recorded, so confidentiality needs to be ensured for all participants.

COREQ checklist for qualitative data studies will be followed (28).

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