A qualitative interview study with parents to identify barriers and drivers to childhood vaccination and inform public health interventions

ABSTRACT

Vaccination coverage in the Federation of Bosnia and Herzegovina, in Bosnia and Herzegovina, has been declining since 2014. This qualitative study aimed to identify barriers and drivers to childhood vaccination for parents. The COM-B (capability-opportunity-motivation-behavior) model was the underpinning theoretical framework. Face-to-face interviews with 22 parents of fully (n = 6), delayed/partially vaccinated (n = 9) and unvaccinated (n = 7) children were conducted. Interviews explored individual factors (capability–knowledge and skills; motivation–attitudes, confidence and trust) and context factors (physical opportunity–information, access, health systems; and social opportunity – social support, norms). Data were analyzed in NVivo using content analysis exploring differences in COM factors by vaccination status and location. Parents of fully vaccinated children typically reported individual and context drivers to vaccination. They accepted vaccination, trusted health workers, and were content with services. Parents of delayed/partially vaccinated children fell into two subgroups: (1) Those who accepted vaccination and attributed delays to their organizational skills or frustration with appointment times. (2) Those fitting the profile of “vaccine hesitant” – generally valuing vaccination and health worker advice, yet with concerns often triggered by media/social media. Parents of unvaccinated children mentioned individual and context barriers to vaccination, notably significant concerns about safety, some distrust of health workers and resentment of mandatory vaccination. Urban/rural differences included urban parents being more likely to report experiences with vaccine shortages and very few had received information leaflets. The study identified complex and inter-related barriers and drivers to parents’ childhood vaccination behaviors. These insights have informed the development of tailored interventions to improve coverage.

KEYWORDS:

• vaccination
• immunisation
• immunisation
• parent
• Bosnia and Herzegovina
• Tailoring Immunization Programmes (TIP)

Introduction

Vaccination uptake in the Federation of Bosnia and Herzegovina (FBiH), in Bosnia and Herzegovina, has been steadily declining since 2014. In 2018, reported coverage for the third dose of the diphtheria-tetanus-pertussis containing vaccine (DTP3) was 72.8% and for the first dose of the measles-mumps-rubella vaccine (MMR 1) was 68.4%;¹ below the 95% target for national coverage stipulated in the European Vaccine Action Plan.² The number of reported cases in an FBiH measles outbreak was 1332. Alongside outbreaks in nearby countries, including Germany, Italy, Romania and Serbia, these data serve as constant reminders of the consequences of low vaccination uptake.³ Furthermore, Bosnia and Herzegovina is considered at high risk of sustained polio transmission following importation due to its suboptimal vaccination coverage.⁴

A growing body of global evidence has shown that the underlying causes of suboptimal vaccination uptake are complex, context-specific and vary by time, place and vaccine.^5–7 This means that local evidence is needed to develop an effective response.⁸ Historically, in FBiH, there has been a lack of data to explain the reasons for declining childhood vaccination coverage. Detailed analysis of disease outbreaks exists^9–11 as does some preliminary insight on the demographic characteristics and vaccination behaviors of parents.^12,13 In 2016, a global vaccination confidence study¹⁴ reported high levels of vaccination skepticism and of effectiveness-related doubts in Bosnia and Herzegovina. However, evidence on factors influencing parent’s childhood vaccination decisions and behaviors has been absent. This is in stark contrast to the extensive global literature.^8,15,16

The WHO Tailoring Immunization Programmes (TIP) approach^17,18 uses social sciences, ethnographic research techniques, and behavioral insights methodology to support countries in this work. Specifically, to identify susceptible groups, diagnose barriers and drivers to positive vaccination behaviors, and segment populations according to behavioral determinants; in order to design tailored interventions to increase vaccination coverage. The theoretical framework underpinning the TIP approach is a modified version of the Capability-Opportunity-Motivation-Behavior model (COM-B).^17–19 This identifies the inter-linked factors of capability (knowledge, skills), physical opportunity (information, access, health systems), social opportunity (support, norms), and motivation (attitudes, confidence, trust) as influencing vaccination behaviors. Capability and opportunity also influence motivation.

In 2017, the Institute for Public Health of the FBiH commenced a TIP project. To address the above-described evidence gap, three formative research studies were conducted from 2017 to 2019: a qualitative interview study with health workers,²⁰ a patient file study in primary care centers (PCCs) to identify differences in the characteristics (e.g., age, number of children, education) of parents who fully/partially/do not vaccinate their children²¹ and a qualitative interview study with parents (the focus of this paper). The study aims were to:

1. Identify the barriers and drivers to childhood vaccination for parents in FBiH

2. Examine whether, and how, these responses vary across and within different groups of parents (those whose children are fully vaccinated, delayed/partially vaccinated or unvaccinated) and by urban and rural locations.

Methods

The study was conducted April 2018 to October 2019.

Ethics approval

All study procedures were in accordance with the ethical standards of the Institute for Public Health of FBiH and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Ethics Committee of the Institute for Public Health of FBiH.

Participants and recruitment

Purposive and convenience sampling was employed. Eligible participants were parents whose youngest child’s vaccination record was included in the above-described patient file study (children born in 2015 and 2016).²¹ The findings of that study had revealed that children living in urban areas had lower vaccination uptake than those living in rural areas. To investigate the reasons for this pattern, we randomly selected three urban and two rural PCCs from those participating in the patient file study to find urban and rural parents. Health workers who had reviewed children’s vaccination records for the patient file study were posted information and then telephoned to discuss the study and to identify parents to be approached for interviews. Within each PCC, parents were selected to reflect a mix of those whose child in the patient file study was fully vaccinated, delayed/partially vaccinated or unvaccinated. Those children were aged 19–35 months at the time of that study. The health workers phoned the parents to seek permission to pass on their contact details to the research team. Researchers (AK, SM, MS, VS) then phoned parents to book an interview. Before the interview began, written informed consent was collected. At the end of the interview, parents received a gift card to thank them for their participation (value equivalent to 16 US$).

Fifty-two parents were invited, 30 declined (whose child in the patient file study was fully vaccinated n = 14, delayed/partially vaccinated n = 9, and unvaccinated n = 7). Reasons for declining were a lack of time, no childcare, or no interest in the study. One parent declined to take part because she does not vaccinate her children. Twenty-two parents (14 urban, 8 rural, 19 mothers, and 3 fathers) were interviewed, representing a mix of vaccination status for their child in the patient file study (see Table 1). Parents had between one and three children.

Table 1. Participant characteristics

		Urban PCC	Rural PCC	Total
Parental status	Mother	12	7	19
	Father	2	1	3
Number of children	1	4	2	6
	2	8	4	12
	3	2	2	4
Child’s vaccination status	Fully vaccinated	4	2	6
	Delayed/Partially	5	4	9
	Unvaccinated	5	2	7

Note: Child is child in patient file study. Fully vaccinated: Received BCG vaccine, three doses of any DTP-containing vaccine (3-valent DTwP, 4-valent DTaP-IPV, 5-valent DTaP-IPV-Hib), three doses of hepatitis B vaccine, three doses of polio and first dose of the MMR vaccine. Delayed/partially vaccinated: Received some (either on time or delayed), but not all (available) recommended vaccines (e.g. BCG, hep B1, and DTP1, but no DTP3 or MMR). Unvaccinated: Never been vaccinated or who just received BCG and hep B at birth.

Data collection

Face-to-face interviews were conducted by AK, SM, MS, VS, all members of the TIP team. They were novice qualitative researchers, having been trained (by CJ) and gained their first experience in conducting the TIP interview study with health workers.²⁰ CJ is a qualitative researcher with over 15 years’ experience who provided training updates and support for all steps of this study. The researchers presented themselves to participants as part of the TIP team and advised that any specific questions about the national immunization program would be answered after the interview. Interviews were conducted in the local language in places that ensured privacy, for example, in room at a workplace, in the PCC, or at the parent’s home. Only the participant and the researcher were present.

Interviews explored parents’ views on their barriers and drivers to childhood vaccination, organized by the modified COM-B framework.^17,18 The topics were access to childhood vaccination services, the role of other people in parental vaccination decision-making, their child’s health in the context of vaccination, for example e.g. , contraindications, and knowledge and views about childhood vaccination. An interview topic guide was used to ensure consistency, although the format was flexible to allow participants to generate naturalistic data on what they viewed important, as well to acknowledge the vaccination position of the parent. The topic guide was developed by brainstorming potential questions to explore the topics of interest, then piloted with two parents (both with delayed/partially vaccinated children) known to the research team, after which small changes were made to some questions to improve clarity. The interviews lasted between 15 and 66 minutes.

Data analysis

The interviews were recorded, transcribed verbatim, and translated into English. The data were then analyzed in English using deductive content analysis;²² and focused on identifying barriers and drivers to positive childhood vaccination practices organized by the modified COM-B model.^17,18 The five steps were as follows:

1. The data analysis team (CJ, AK, SM, MS, VS) read three interview transcripts (one per vaccination group) and agreed key ideas for the categorization matrix that addressed the study aims, COM factors, and interview topics.

2. CJ developed the categorization matrix; and this was pilot tested by the data analysis team using a further three interview transcripts. The matrix was then finalized and set up in NVivo 11.

3. CJ, MS and VS coded the interview data to the categorization matrix. The first transcripts coded by VS and MS were checked by CJ to facilitate intercoder consistency.

4. The data analysis team wrote up the analysis, exploring differences and similarities by participant characteristics (location, vaccination group)

5. KBH reviewed these findings with particular attention to checking the links to the COM factors, and facilitated discussions related to analysis and interpretation over a 3-day workshop with the TIP team.

Results

Parents’ views on their barriers and drivers to childhood vaccination are presented below, organized by the modified, inter-linked COM factors (capability, physical opportunity, social opportunity, motivation).^17,18 Where there were differences by location (urban/rural) or vaccination group (fully, delayed/partially vaccinated or unvaccinated) these are highlighted; otherwise, parents’ views were the same.

Capability

The capability barriers and drivers to vaccination related to the parents’ knowledge of vaccination and vaccine-preventable diseases as well as their skills in planning and organizing their child’s vaccination.

Knowledge of vaccination and vaccine-preventable diseases

Parents generally had a good understanding that vaccination protects children against communicable diseases and does so by stimulating the immune system to produce antibodies. Also, most parents could name some diseases, typically mentioning measles, tuberculosis, whooping cough, hepatitis, mumps, and polio. Half the parents from rural locations could not name any.

In terms of understanding the risk of contracting a vaccine preventable disease and the severity of these diseases, parents of fully and delayed/partially vaccinated children generally understood that their children were less likely to catch a vaccine-preventable disease once vaccinated and recognized that these diseases could be serious. Amongst parents of unvaccinated children, this knowledge was lacking or rather their interpretation of risk information was different (described in Attitudes and risk perceptions). As an example, a parent did not view measles as serious, thinking that his child had sufficient natural immunity for protection (Quote C1, Table 2).

Table 2. Illustrative quotes for individual factors: capability and motivation¹⁷⁻¹⁹

COM factor	Theme	Quote ID	Participant ID and quote
Capability	Knowledge of vaccination and vaccine-preventable diseases	C1	“It’s [measles] not that serious. Lately, we have measles cases every now and then, and the deaths, generally those were people with compromised immunity. So, people with well-built immunity, they don’t die from measles. We have managed to build a good immunity system for our child.“ (U_VS_OV3: urban, unvaccinated)
	Planning and organizing vaccination	C2	“I’d get them [child’s vaccinations] following my own initiative. I call the health center and ask them when I can bring my child.” (U_AK_DV1: urban, delayed/partially vaccinated)
		C3	“We took a picture in the health center of how it works by month, and so we brought her.” (U_VS_DV1: urban, delayed/partially vaccinated)
		C4	“Essentially, the reason of his non-vaccination, and of the daughter as well, is the lack of time and poor organization. It was unintentional, no time, organization, little consideration.” (U_AK_DV2: urban, delayed/partially vaccinated)
Motivation	Attitudes and risk perceptions	M1	“If you don’t vaccinate, I think the risk of catching a disease is a bit higher than for children who are vaccinated, and that’s why, essentially, I want the best for my child, and that’s why I vaccinate them.” (U_SM_PV5: urban, fully vaccinated)
		M2	“The child is not prone to illness at all. We’ve managed to build a good immune system for him, and we think that with less introduction of chemical things in his body we’ve made it easier for him to build his immunity.” (U_VS_OV3: urban, unvaccinated)
		M3	“You inject a virus into a small child who is yet to build its defense system. So, the idea is to inject five viruses into my child at the same time and hope that he copes with it. Some children suffer consequences from those vaccines. I don’t want to let my child, to expose my child to all those viruses at the same time. I am not informed but simply it’s common sense.” (U_VS_OV4: urban, unvaccinated)
		M4	“Well, I’d vaccinate if I knew it is administered in other countries, and then I would know that it’s already [being used] somewhere, that it’s been studied. I don’t think they administer vaccines that haven’t been studied.” (R_MS_DV1: rural, delayed/partially vaccinated)
		M5	“Vaccines are procured through public procurement. They make a specification on the basis of which they procure a vaccine, meaning to say, every specification includes certain criteria, of what it should be like, what it must contain and certain producers, meaning to say it should be detailed.” (U_SM_DV2: urban, delayed/partially vaccinated)
		M6	“I got some information that here these vaccines are not stored as they should be, like in cold, like, in a little box as it happens, like, abroad. For example, today we have fifteen children scheduled, they take from the storage room that isn’t cold, not a refrigerator, they take out these vaccines, put in the fridge, and vaccinate our children. When you hear all these stories, you wonder.” (U_VS_DV1: urban, delayed/partially vaccinated)
		M7	“I don’t oppose vaccination of children. Regarding the [MMR] vaccine, my child wasn’t vaccinated for the reason that since she started kindergarten, she constantly has some colds and her nose is running and whenever I go to see the doctor, no one dared to administer that vaccine or any other vaccine.” (U_VS_DV1: urban, delayed/partially vaccinated)
		M8	“We didn’t want to vaccinate with the MMR because of the media propaganda. Well, the parents speak out because their children got autism, they stopped talking. Like all vaccines, when children get them, the brain gets, like, how shall I put it, swells a bit, and from this vaccine most, and that may be the reason and trigger of something, these children, well, they have consequences after receiving this vaccine.” (U_VS_OV1: urban, unvaccinated)
	Confidence and trust	M9	“[I trust] the pediatrician when it comes to my child’s health. I most believe it there because of the level of expertise.” (R_MS_DV1: rural, delayed/partially vaccinated)
		M10	“I don’t trust our pediatricians, specifically ours, at our health center. They had no answer to some questions we asked, not about vaccines or they gave an incorrect answer. Somehow sometimes I have a feeling that I know some things better than they do.” (R_MS_OV2: rural, unvaccinated)

Planning and organizing vaccination

There was good awareness of the childhood vaccination schedule, even if parents were not familiar with the fine details. They knew about it from talking to their pediatrician or nurse, reading it in their child’s health insurance card or seeing it on a poster at the PCC.

Amongst the parents of fully and delayed/partially vaccinated children, there was an even split of those who relied completely on the PCC to advise when to bring their child for vaccination (described in Health systems); and those who were more proactive in scheduling their child’s vaccination. This second group used strategies of having a copy of the vaccination schedule to follow either from the internet or as a photo of a poster in the PCC; following the dates recorded in their child’s health insurance card and proactively contacting their PCC when they knew their child’s vaccination was due (Quotes C2–3, Table 2). Amongst those with partially/delayed vaccinated children, some acknowledged that delays were due to their own poor organization skills (Quote C4, Table 2). This was unrelated to their levels of independence in scheduling. Parents of unvaccinated children were not asked about planning their children’s vaccinations as we assumed that they did not do this.

Physical opportunity

Physical opportunity factors for parents reflect the external physical context for vaccination. Here we present their views on access (location of their PCC, affordability, vaccine availability), convenience and appeal of vaccination services (appointment times, waiting time, and waiting and consultation areas), health systems (reminders), vaccination legislation, and availability of written information.

Access

The location of the PCC and financial costs were not perceived as barriers to attending for vaccination. The PCC was usually close to home and, if not, parents took a taxi, public transport, or drove, describing these travel costs as irrelevant to their decision to bring their child for vaccination (Quote PO1, Table 3).

Table 3. Illustrative quotes for context factors: physical and social opportunity¹⁷⁻¹⁹

COM factor	Theme	Quote ID	Participant ID and quote
Physical Opportunity	Access	PO1	“I need to pay for the ride to take my children there, I have no other costs, but of course I come.“ (R_MS_PV1: rural, fully vaccinated)
		PO2	“So far, it’s never happened they don’t have a vaccine, meaning to say, I trust they have them.” (R_MS_DV1: rural, delayed/partially vaccinated)
		PO3	“Well, there were cases the vaccine was not available, but we arranged it with pediatricians in advance. If they knew there wouldn’t be sufficient stocks, they’d say come in a month and a half or phone us before to check whether it’s available or not, it’s not that we would come to the clinic only to go back without being vaccinated.” (U_AK_PV1: Urban, fully vaccinated)
	Convenience and appeal of vaccination services	PO4	“My child’s health is a priority for me, of course I’ll skip work and all obligations to take him, so that it’s not a barrier for me personally.” (U_AK_PV1: urban, fully vaccinated)
		PO5	“They don’t ask you when you can come, they simply give you the time. And you know how difficult it is here to leave work. What could help me [vaccinate my child] is that, we can go and visit the doctor without an appointment.” (U_VS_OV1: urban, unvaccinated)
		PO6	“This is a children’s ward, so it’s decorated in different colors and drawings. It’s very neat, nice.” (R_MS_PV1: Rural, fully vaccinated)
		PO7	“The situation is very good, at the health center because children who are ill are separated from healthy children, so there are two waiting rooms and I like it very much, and it suits me because it isn’t fair that a child who’s healthy and comes there for a reason like vaccination or simply for any examination or a health certificate should be exposed to bacteria and viruses of the ill children.” (U_VS_PV1: urban, fully vaccinated)
		PO8	“Well, the waiting rooms at the health center aren’t quite adequately structured. Where I used to vaccinate my child, the place had, separate entrances for healthy and ill children, which was in line with protocols, probably. However, in the municipality, the health center (name) that’s not the case, so I’m not happy. Healthy and ill children are mixed when we get there for vaccination.” (U_AK_PV2: urban, fully vaccinated)
	Health systems	PO9	“No, never [have I received a reminder]. Every time I come for vaccination, when talking casually and consulting with the pediatrician we agree on a date of the next vaccination, but a reminder of some sort, via E-mail, mobile telephone, no.” (U_AK_PV1: urban, fully vaccinated)
	Legislation	PO10	“Frankly, I’d introduce it [the law] for children who can’t for health reasons [be vaccinated]. For children who are sufficiently healthy and should receive it. There is a large number of unvaccinated children who for no medical reason, who can be vaccinated. I don’t know whether this [law] would deprive someone of the freedom of choice, but believe me, in this case, I think I would [implement it].“ (U_SM_DV1: urban, delayed/partially vaccinated)
		PO11	“No state can, not one man in the world can tell someone what to do with their life. If I didn’t want to vaccinate my child, well, the laws are there to be violated, I would break that, no matter what the law says.” (U_VS_DV1: urban, delayed/partially vaccinated)
	Availability of written information	PO12	“[I want to know] everything, let’s say, the basics. Why should we vaccinate children or not, and what am I administering to my child? What sort of bacteria is it that will awaken her immune system to recognize tomorrow that she wouldn’t fall ill with measles or mumps? And I’d like that someone tell me the components of the vaccine and which component will protect her from something. Also, what harm can come to her. So, I have never received feedback on what I have just told you now.” (U_VS_DV1: urban, delayed/partially vaccinated)
		PO13	“I visit the Internet because there, you can find anything, anything you’re interested in. I always try to find what suits me; meaning to say, the negative views on vaccination, I avoid. I always check who’s posted a blog, who’s written an article, who’s given an interview. I always check it and then some things there must be taken with caution.” (R_MS_DV1: rural, delayed/partially vaccinated)
		PO14	“There are a lot of stories you read about bad experiences. There are a couple of forums, which I follow for pregnant ladies and breastfeeding mothers, well, literally it’s a big paradox in the way people think, and now, if I say I’m going to vaccinate my child, there will be five comments, I’m like this, I’m like that, why vaccinate, then another mother says, I don’t know, I won’t.” (U_SM_DV1: urban, delayed/partially vaccinated)
		PO15	“I know that at one point there was a campaign against vaccinating children, then the media, TV certainly it reached me. It was in the newspapers, and I’m sure sort of fear crept in and thoughts about whether vaccines are safe, what side effects they can bring about, so that all of us certainly, maybe, we are a bit scared and would postpone.” (U_AK_DV2: urban, delayed/partially vaccinated)
Social Opportunity	Social support	SO1	“I was lucky with my son, I had a wonderful pediatrician, and trusted the pediatrician completely and did not think about anything. When she retired, I kept changing pediatricians. I didn’t have anyone who would give me full and true information [about vaccination]. At certain moments I felt they weren’t completely certain in that area, that they didn’t master it, fully, the topic.” (U_AK_DV2: urban, delayed/partially vaccinated)
		SO2	“I talked with the doctor about the MMR vaccine, but of course, doctors aren’t willing to confirm 100% there will be no adverse effects, that it can’t happen. I had no answer from the doctor.” (U_VS_OV1: urban, unvaccinated)
	Social cues, norms and values	SO3	“There have been situations at work, we had a meeting, and then had a coffee afterward and vaccines were mentioned. I said something like my child hasn’t been vaccinated, then the colleagues attacked me, how come, here-there, and then I went silent, simply stopped, I don’t want to, to create a conflict of any sort, so I rarely speak about it.” (U_VS_OV3: urban, unvaccinated)
		SO4	”The ultimate decision is mine and of my husband, meaning to say, no one can assume making this decision for me and can’t influence anything in the sense that they impose something I don’t want.” (U_SM_DV2: urban, delayed/partially vaccinated)
		SO5	“I know a lady said once that, she’s brought her child for vaccination today, and then the next day she ended up in hospital with some major inflammation and the child spent a long time in hospital. It took major efforts to cure him.” (R_MS_PV1: rural, fully vaccinated)

There was a clear urban/rural difference in parents’ views about vaccine availability. Approximately half of parents (predominantly in rural locations) had never experienced any problems with vaccine availability. Many urban parents recalled an occasion where a vaccine was not available, with some explaining how their PCC had effectively managed that situation (Quotes PO2–3, Table 3).

Convenience and appeal of vaccination services

Views on the convenience of appointments for vaccinations also varied by location. Parents living in rural locations (all vaccination groups) and urban parents of fully vaccinated children were content with appointment availability, commenting that finding time for vaccination was a priority for them (Quote PO4, Table 3), whereas, amongst urban parents of delayed/partially or unvaccinated children, there was some frustration that vaccination sessions or specific appointments are allocated by the PCC and conflict with working hours. Suggestions were to offer drop-in sessions or appointments outside of working hours, both of which were already in place in some PCCs (Quote PO5, Table 3).

Parents readily accepted that they may have to wait in the PCC for their child to be vaccinated. The consensus was that this did not influence their decision to bring their child for vaccination. There were different opinions about the waiting room facilities. Positive comments focused on cleanliness and child-friendly décor with brightly painted walls and cartoon characters (Quote PO6, Table 3). The negatives were that some buildings were old, crowded and lacked baby changing/feeding facilities. Some urban parents mentioned the importance of keeping the healthy and sick children separate in waiting areas. Of these parents, there was an even split between those who perceived this is done or not done in their PCC (Quotes PO7–8, Table 3).

Health systems

Most parents had not routinely received reminders from the PCC to bring their children for vaccination. Instead, as described in Planning and organizing vaccination, they kept track of their child’s schedule themselves or relied on a health worker to mention a forthcoming vaccination during a consultation (for vaccination or other health issues) (Quote PO9, Table 3). Half the rural parents had received a reminder telephone call. A few parents with delayed/partially vaccinated children mentioned not receiving a reminder after a postponement due to contraindications, often using this to justify further delays. Suggestions for reminders were for the PCC to send an e-mail or SMS.

Legislation

Childhood vaccination is mandatory in FBiH and opinions on this starkly differed across vaccination groups. All parents with fully vaccinated children, and most of those with delayed/partially vaccinated children supported the law. Their rationale being that this protects children who cannot be vaccinated and those whose parents would prefer not to vaccinate (Quote PO10, Table 3). A small minority was not aware of the law.

In contrast, parents of unvaccinated children and one urban parent of a delayed/partially vaccinated child rejected the concept of mandatory vaccination. They observed that it is not compulsory in western Europe and stated that it did not influence their decision about vaccinating their children. Comments included that it is “ridiculous” to tell people how to live their life, they “do not give a damn about the law” and would pay a fine rather than vaccinate (Quote PO11, Table 3).

Availability of written information

Official leaflets, the internet, social media, and media were the popular information sources for parents, with some notable differences in views on their credibility and influence across vaccination groups and by location.

Most urban parents had not received any “official” written information on vaccination from their PCC. Parents of delayed/partially vaccinated or unvaccinated children wanted more official information. They requested information on why you vaccinate, the vaccination schedule, components of vaccines, potential risks of different vaccines, what triggers the child’s immune system, contraindications and what is the risk of delaying vaccination (Quote PO12, Table 3). Parents of unvaccinated children were additionally curious about the origin, procurement and storage of vaccines.

The internet was unanimously seen as an easy, fast way to access all types of information about vaccination. Irrespective of vaccination group, some parents carefully considered the credibility of the information source, whilst others were more trusting (Quote PO13, Table 3).

Social media was viewed more cautiously with “storytellers” seen as anonymous nonexperts expressing conflicting personal opinions. That said, despite this critique, most participants, particularly those in urban locations, used social media and followed vaccination stories and debates (Quote PO14, Table 3). Many urban parents with delayed/partially vaccinated or unvaccinated children referred to stories and discussions about adverse events following immunization, especially rumors linking MMR (measles-mumps-rubella vaccine) to autism, and admitted to being influenced by these in their decision-making. This influence was not evident amongst any rural parents or urban parents with fully vaccinated children.

Finally, the presence of vaccination stories in the media was unanimously acknowledged, with coverage perceived to be mainly negative, for example, about stories of mercury in vaccines, inadequate vaccine storage and adverse events, particularly MMR and autism. As with social media, it was parents with delayed/partially or unvaccinated children who spoke of being influenced by the media (Quote PO15, Table 3). A few reported postponing after having seen some media stories. Conversely, two parents had been encouraged to vaccinate their child after seeing a TV debate between a pediatrician promoting vaccination and a parent who refused all childhood vaccinations.

Social opportunity

Social opportunity factors related to the social context for vaccination. Parents’ views on social support (advice from health workers) and social cues, norms and values (family, friends and rumors) are presented below.

Social support

It was very clear from parents’ accounts that they discussed childhood vaccination with their pediatrician or another health worker. Those with fully or delayed/partially vaccinated children were generally satisfied with this communication, typically describing their pediatricians as supportive and skilled in answering their questions. Just a small minority was less positive, mentioning pediatricians whom they perceived to be less knowledgeable or have their own vaccine hesitancy (Quote SO1, Table 3). Parents of unvaccinated children and some urban parents of delayed/partially vaccinated children were noticeably less happy with their pediatrician. They expressed frustration that doctors did not discuss vaccination in enough detail or did not present as “completely” confident in vaccination because they were not able to guarantee that vaccines are 100% safe (Quote S02, Table 3). Some of these parents had carefully selected a doctor who was more sympathetic to their views on vaccination.

Social cues, norms and values

Many parents had discussed vaccination with family and friends, some of whom were health workers. They recalled conversations with people who had the same or different opinions to them. The extent to which parents saw themselves as influenced by these opinions varied. Urban parents of delayed/partially vaccinated children, and those with unvaccinated children (rural and urban) appeared to be more selective in whom they discussed vaccination with. They described seeking seek out family members with similar views to their own, avoiding those with opposing opinions or avoiding the topic completely with friends to avert being criticized (Quote SO3, Table 3). Some only discussed vaccination with their partner commenting that these decisions were solely their responsibility as parents (Quote SO4, Table 3).

Rumors were another potential source of social influence. Many parents had heard stories about children who were said to have had an adverse event following immunization usually described as serious, and often linked to the MMR vaccine (Quote SO5, Table 3). In contrast, very few rumors referred to children who had experienced a vaccine-preventable disease. As with social media, some parents admitted to being influenced by these stories.

Motivation

Motivation refers to the factors that motivate or demotivate parents to vaccinate their children and is influenced by the above-mentioned factors (capability, physical and social opportunity). We present here parents’ attitudes and risk perceptions (about the immune system, new vaccines, vaccine safety, and MMR), their intentions, and their confidence and trust.

Attitudes and risk perceptions

As we might expect, parents of fully vaccinated children overwhelmingly expressed positive attitudes toward vaccination and their risk perceptions were drivers to vaccinating their children (Quote M1, Table 2). The majority of those with delayed/partially vaccinated children were also generally positive, although some had specific concerns, presented below. For all parents of unvaccinated children, the incomplete vaccination status of their children was linked to their attitudes and risk perceptions about vaccination, often rooted in poor knowledge (described in Knowledge of vaccination and Vaccine-Preventable Diseases). Their beliefs included that the risk of vaccination is greater than the risk of disease, that their children are healthy (“never ill”) so do not need vaccination, and vaccination should be delayed until children are older and stronger (Quote M2, Table 2).

In terms of specific concerns, a minority of parents with delayed/partially vaccinated children believed that vaccination, especially combination vaccinations, over burden a child’s immune system. Most parents with unvaccinated children also held this belief. Views included that anything introduced artificially into the body is a stressor, immunity drops every time a vaccination is administered and “cocktails” of vaccines are too much for a young child to cope with (Quote M3, Table 2). One parent referred to vaccines as a “mini time bomb.” These parents were also more cautious about new vaccines, requesting an explanation of why they are needed, reassurance about the producer and of safety, including that they have been tested or used in other countries (Quote M4, Table 2).

Of parents with delayed/partially vaccinated children, approximately half were confident that vaccines are safe, understanding that they meet a certain quality standard (Quote M5, Table 2). The other half, along with all parents of unvaccinated children, believed vaccine quality to be poorer in the FBiH than in western Europe attributing this to stories they had heard about low budgets, cold chain issues, and corruption in the pharmaceutical industry (Quote M6, Table 2).

More parents of delayed/partially vaccinated children expressed concerns about MMR than for the above-described issues. Many had postponed the first dose because of worries about autism or about the vaccine being “live” and containing eggs or offering the justification that their child had an acute infection and they were advised to postpone by the pediatrician (Quote M7, Table 2). Parents with unvaccinated children, especially those in urban locations, were more likely to decline MMR rather than postpone; believing that having the disease was better protection than the vaccination or fearful that the vaccine is linked to autism. Irrespective of the reason for MMR concerns, parents attributed these to the internet, media, social media, and circulating rumors (Quote M8, Table 2) (see Availability of written information and Social cues, norms and values).

Intentions

All the parents with fully vaccinated children intended to continue to vaccinate their children according to the schedule. This was also the case for most of the parents with delayed/partially vaccinated children, even when they had some concerns described above. There was an intention amongst some with delayed/partially or unvaccinated children to vaccinate “in the future” when their child is older and stronger. Only two parents explicitly stated that they did not intend to ever take their children for vaccination.

Confidence and trust

For all groups of parents, confidence and trust appeared to be associated with the perceived motive and credibility of an information source. Scientific studies, professional literature, and medical professionals were generally viewed as more trustworthy than parents or friends. Indeed, the accounts of many parents of fully and delayed/partially vaccinated children revealed an implicit trust of health workers, especially pediatricians and doctors, valuing their expertise in childhood vaccination (see Social support) (Quote M9, Table 2). Those who were less trusting of their health worker, typically with unvaccinated children, questioned their knowledge and allegiance with the pharmaceutical industry (Quote M10, Table 2). A small minority of urban parents was suspicious of the Government, state institutions, and regulatory agency. This distrust seemed to be grounded in their general belief system rather than specifically to vaccination.

Discussion

To our knowledge, this is the first in-depth qualitative study in FBiH to explore parents’ views on their barriers and drivers to childhood vaccination. It provides important evidence about capability, physical and social opportunity, and motivation factors. These findings, together with insight from health workers²⁰ and data on the characteristics of fully, delayed/partially vaccinated and unvaccinated children and their parents²¹ provide vital evidence-based public health data to understand the reasons for the suboptimal childhood vaccination uptake. Importantly, this insight can inform the development of tailored interventions, needed particularly in urban locations where the likelihood of a child being fully vaccinated is three times lower than for a child living in a rural setting.²¹ More widely, the study findings contribute to the small, but emerging evidence base on vaccination acceptance and demand in Central and Eastern Europe,^23–25 to the portfolio of TIP research^26–28 and to the global literature on factors influencing parent’s childhood vaccination decisions and behaviors.^8,15,16

We found some similarities across the three groups of parents in urban and rural locations. Parents had a basic awareness of the reason for vaccination, knew there was an official schedule and could name some vaccine-preventable diseases. There was also consensus that the location of the PCC, associated travel costs, and waiting time were not barriers to bringing their child to be vaccinated. Overwhelmingly, parents did not routinely receive formal reminders. The other commonality was the use of a wide variety of information sources, both written and verbal, although trust in and reliance on these different sources varied considerably across parent groups as discussed below. Two urban–rural differences independent of parent group emerged. Urban parents were more likely than rural parents to report experiences with vaccine shortages and very few had received information leaflets. Confirming this, our patient file study²¹ revealed considerable issues regarding shortages of DTP vaccines containing acellular pertussis. This was resolved gradually from the second half of 2016 until 2019 when a multiyear tender was secured resulting in reduced vaccine price, sustainable supply, and amended vaccine schedule. Currently, no official leaflets are routinely given to parents in PCCs, although information in local languages is available online (e.g., https://vakcine.ba/). Given the strongly expressed wish for more information, it is a clear recommendation to ensure that parents can easily find and access, understand and act upon trustworthy information about vaccines, immunity and immunization in FBIH.²⁹

Multiple differences were evident across the three parent groups for individual capability and motivation factors as well as for contextual social and physical opportunity factors. Barriers specific to urban parents within these groups also emerged. We discuss each parent group in turn and consider the implications of the findings for developing appropriate, tailored interventions to strengthen drivers and remove barriers to childhood vaccination.

As one might expect, parents with fully vaccinated children typically reported capability, physical and social opportunity, and motivation factors that were drivers to vaccination. They were generally happy with immunization services, accepted mandatory vaccination, and trusted their health workers. Moreover, they were not particularly influenced by negative media reporting or rumors of adverse events shared by family, friends or social media. Instead, they expressed attitudes and risk perceptions consistent with positive vaccination behaviors. Just over half of children (59%) in our patient file study²¹ were fully vaccinated on time according to the schedule. It is imperative to ensure that individual and context drivers to vaccination remain in place so that these parents continue to vaccinate their children according to the national schedule, including access to easily understood information, convenient vaccination hours and reminders.

This study identified two subgroups of parents who delayed or partially vaccinated their children. Reassuringly, both subgroups intended to vaccinate their children in the future and so there is potential for increasing vaccination coverage if their barriers to vaccination are understood and addressed.

The first subgroup of parents were accepting of vaccination and attributed delays to their poor organizational skills or frustration with appointment times (particularly those in urban locations). Half of these parents relied on informal prompts from their PCC. Effective interventions are possible to address these physical opportunity barriers. Patient reminder and recall systems can improve vaccination uptake³⁰ and going forward, these parents would benefit from formal reminders for scheduled and postponed vaccinations. Drawing on the findings of all three TIP studies,^20,21 the Institutes for Public Health of FBiH and the Republic of Srpska in collaboration with UNICEF BiH have launched and are evaluating a mobile application “My Calendar of Immunization.” This app provides immunization-related information, tracks a child’s vaccination status and sends notifications for immunization (7 days before the appointment) with a reminder 30 days later if the appointment is missed. In addition, increasing the convenience of vaccination services by offering extended opening hours and drop-in vaccination sessions can help busy parents.¹⁷ Whilst some PCCs already offer this flexibility,²⁰ there appears to be scope for reviewing the management of PCCs to expand this or perhaps better informing parents of these opportunities, particularly in urban settings.

The second subgroup fitted the typical profile of “vaccine hesitant” parents^8,31,32 for whom capability and motivation barriers and drivers are finely balanced. They understood and valued vaccination, accepting that it is mandatory and most of them trusted the advice of health workers. However, they had some misperceptions and concerns, for example, about combination vaccinations, overloading their child’s immune system and commonly worried about MMR, often choosing to postpone until the child is stronger or more developed. Urban parents in this subgroup appeared to want their pediatrician to guarantee the 100% safety of vaccines. They were also more selective about which family/friends they discuss vaccination with and admitted to being negatively influenced by social media and media reporting of children suffering alleged vaccine-related adverse events.

There is a lack of evidence of effective standalone interventions to tackle vaccine hesitancy³³; however, it is well accepted that a major influence on whether a hesitant parent accepts or rejects a vaccine is the interaction with their vaccine provider.^34–36 For this subgroup of parents, there is a clear need for skilled communication by trusted, confident and knowledgeable health workers to address concerns and misperceptions (such as those related to the ability of the immune system to cope with vaccines), strengthen confidence in vaccination, and develop resilience to negative media, social media, and social network messaging.^32,37,38 A challenge to this, evident,²⁰ but not unique to the FBiH, is misperceptions and vaccine hesitancy amongst some health workers^16,24,38 and self-reported accounts of agreeing to parents’ requests to postpone vaccination to maintain good relationships and because they fear repercussions should something go wrong.²⁰ A multipronged approach to address the interlinked capability and motivation barriers of both health workers and parents is recommended,³⁹ including efforts to build health worker knowledge and confidence in areas related to technical aspects of immunization and to strengthen their skills to recognize, understand and address concerns and vaccine hesitancy among parents. In 2019 training on interpersonal communication for immunization was delivered to 219 health workers across nine cities in FBiH. Insight from the TIP studies informed the adaptation of resources from UNICEF and Johns Hopkins Center for Communication Programs⁴⁰ to the context in Bosnia and Herzegovina. In addition, educational material on vaccine-preventable diseases and vaccination by the European Society for Pediatric Infectious Diseases has been distributed to pediatricians working on immunization in PCCs. These are good first steps; however, a concerted and continued effort over the years is required to address the issues identified.

Finally, parents with unvaccinated children in this interview study referred to capability, physical and social opportunity and motivation factors barriers to vaccination. Their decision not to vaccinate appeared to stem from significant concerns about vaccine safety; and social media (for urban parents), media, and rumors were acknowledged to influence their attitudes and risk perceptions. Some distrust of health workers as well as frustration with a lack of information and safety guarantees from doctors was evident, whilst wider distrust of Government, state and regulatory agencies was voiced by some urban parents. Finally, most resented mandatory vaccination, and some urban parents were frustrated with appointment availability. These barriers are consistent with those of parents who are skeptical of vaccination elsewhere.^34,41

It is generally accepted that vaccine refusers are less likely to change their mind, so aside from keeping the “door open” and maintaining trustful health worker–parent relationships,⁴² efforts to increase vaccination coverage should be directed toward the vaccine hesitant group as a first priority.³⁴ At the outset of the TIP project, there was a perception amongst key stakeholders that such antivaccination sentiment, a relatively recent phenomenon in the Balkan countries^43,44 prevailed amongst parents. This assumption was challenged by the finding that only 2% of children in the patient file study²¹ were completely unvaccinated and just 8% had only received their BCG and first dose of HepB administered at birth. The same goes for this study, where, notably, five out of seven of the parents with unvaccinated children had some intentions to vaccinate their child in the future, thereby offering an unexpected opportunity to move these parents toward vaccinating. They appeared more hesitant than refusing in their interviews.

The interventions (app for parents, training for health workers) that have been put in place in FBIH whilst not directly targeting these parents, may spillover to positively impact on their childhood vaccination decisions and behaviors. Evaluation of these interventions is ongoing; however, an increase in coverage from 2018 to 2019 for DTP3 (72.8% to 80.2%) and MMR1 (68.4% to 79.0%) (Institute for Public Health of Federation of Bosnia and Herzegovina 2020) seems promising.

Strengths and limitations

It is important to reflect on the strengths and limitations of this study. First, we interviewed a mix of parents whose youngest child is fully, delayed/partially vaccinated or unvaccinated based on their child’s file at their PCC. We deliberately included more urban parents because our patient file study²¹ revealed lower coverage in urban settings. The final sample enabled us to identify important differences in their accounts which can inform tailored strategies. We do not have demographic data for parents so cannot comment on how age, education, etc. may be associated with their child’s vaccination status. Thirty parents across the three parent groups declined to be interviewed and we cannot know for certain if their accounts would be different to those of the study participants. However, we achieved data saturation (where no new themes were emerging) and captured good diversity of views. This, and the rigor of the study design and conduct, gives us confidence in our findings and generalizability (as a qualitative concept) to other parents attending these PCCs and across the FBIH.⁴⁵

Conclusion

This qualitative study focusing on parent perspectives provided important insights in barriers and drivers to childhood vaccination related to individual capability and motivation of parents as well as external social and environmental influences. Whilst not unique to FBiH, they are unique within the current social context. The findings offer clear guidance for addressing the problem of declining vaccination coverage in FBiH, particularly in urban areas, and are already being used to tailor interventions to move parents with delayed/partially vaccinated and unvaccinated children toward vaccination.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

TIP advisory group

• Goran Čerkez, Federal Ministry of Health, Federation of Bosnia and Herzegovina, Bosnia and Herzegovina

• Zlatan Peršić, Federal Ministry of Health, Federation of Bosnia and Herzegovina, Bosnia and Herzegovina

• Davor Pehar, Institute for Public Health of the Federation of Bosnia and Herzegovina, Bosnia and Herzegovina

• Mirsada Mulaomerović, Institute for Public Health of the Federation of Bosnia and Herzegovina, Bosnia and Herzegovina

• Victor Olsavszky, WHO Country Office in Bosnia and Herzegovina

• Fatima Čengić, UNICEF Bosnia and Herzegovina

• Amra Junuzović, Health Centre of Sarajevo Canton, Bosnia and Herzegovina

• Jelena Kalinić, Society for Science Advocacy “Science and the World,“ Bosnia and Herzegovina

Authors’ contributions

SM co-conceived the work, co-led on the design and development of the study protocol, conducted the interviews and data analysis, co-led on the interpretation of the study findings, contributed to drafting, and revising the manuscript.

AK co-conceived the work, contributed to the design and development of the study protocol, conducted the interviews and data analysis, contributed to interpretation of the study findings, drafting, and revising the manuscript.

KBH co-conceived the work, co-led the design and development of the study protocol, co-led on the interpretation of the study findings, contributed to drafting, and revising the manuscript.

VS co-conceived the work, contributed to the design and development of the study protocol, conducted the interviews and data analysis, contributed to drafting, and revising the manuscript.

MS co-conceived the work, contributed to the design and development of the study protocol, conducted the interviews and data analysis, contributed to drafting, and revising the manuscript.

CJ co-conceived the work, co-led the design and development of the study protocol, conducted data analysis, contributed to interpreting the study findings, co-led on drafting, and revising the manuscript.

All authors approved the submitted manuscript and are accountable for all aspects of this work.

Acknowledgments

The TIP team would like to thank the parents who took part in the study and health workers who facilitated recruitment. We are grateful to Mirza Palo and Victor Olsavszky at the WHO and the TIP Advisory Group (listed below) who have advised on all steps of the TIP process.

Additional information

Funding

The study was funded by the WHO Regional Office for Europe. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the World Health Organization.