Assessing Community Acceptance of Maternal Immunisation in Rural KwaZulu-Natal, South Africa: A Qualitative Investigation

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Study Justification:
– Maternal immunization has significant benefits but uptake remains low in many areas.
– This qualitative study aimed to assess factors influencing pregnant women’s decision to engage with maternal immunization in rural KwaZulu-Natal, South Africa.
– Understanding these factors is important in facilitating vaccination uptake in low-resource settings.
Highlights:
– Traditional customs and institutional barriers, such as low-quality health service delivery, long queues, distance to health facilities, vaccine stockouts, and low levels of maternal knowledge, influence the choice to engage with maternal immunization.
– Social norms, attitudes, and cultural beliefs also shape health behavior and are strong motivators of behavioral change.
– The study contributes to the understanding of maternal immunization uptake in low-resource settings.
Recommendations:
– Address barriers to care, including improving the quality of health service delivery, reducing waiting times, and ensuring vaccine availability.
– Increase maternal knowledge about the benefits of immunization and address misconceptions.
– Consider social norms and cultural beliefs in designing interventions to promote maternal immunization.
Key Role Players:
– Healthcare providers: Responsible for delivering immunization services and providing accurate information to pregnant women.
– Community leaders: Can influence social norms and promote acceptance of maternal immunization.
– Government officials: Responsible for policy decisions and resource allocation to improve health service delivery.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers to improve service delivery.
– Communication and education campaigns to increase maternal knowledge about immunization.
– Infrastructure improvements to reduce waiting times and improve access to health facilities.
– Vaccine procurement and supply chain management to ensure availability.
– Monitoring and evaluation to assess the impact of interventions and make necessary adjustments.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is qualitative, which provides valuable insights into the factors influencing maternal immunisation uptake in rural KwaZulu-Natal, South Africa. The researchers used a purposive sampling method and conducted in-depth interviews with 28 pregnant women and key informants. Data analysis was conducted using a modified Health Belief Model framework. The study provides a detailed description of the study participants, data collection methods, and data analysis approach. However, the abstract does not mention the limitations of the study or the generalizability of the findings. To improve the strength of the evidence, the researchers could consider including a larger sample size, conducting interviews with a more diverse group of participants, and addressing the limitations and potential biases of the study in the abstract.

Despite the significant benefits of maternal immunisation, uptake remains low in many parts of the world. In this qualitative study, we aimed to assess the factors that influence pregnant women’s decision to engage with maternal immunisation in rural KwaZulu-Natal, South Africa. We conducted in-depth interviews with a total of 28 purposively sampled pregnant women and key informants using semi-structured topic guides. Data analysis was conducted using a modified Health Belief Model framework that included constructs of barriers to action, modifying factors of cue to action and perceived social norms. The findings show that traditional customs and institutional barriers such as low-quality health service delivery, long queues, and distance to the health facilities, immunisation vaccine stockouts and low levels of maternal knowledge influence the choice and decision to engage with maternal immunisation. Understanding health-related behaviours and addressing barriers to care is important in facilitating vaccination uptake. This study contributes to the understanding of maternal immunisation uptake in low-resource settings.

This study was conducted in rural uMkhanyakude district of northern KwaZulu-Natal. This district is one of the poorest in South Africa, with 98% of the population living in rural homesteads; 22% have access to safe water; only 10% of households are within a short distance, approximately 4.72 km, of a health clinic [12,13]. The district is situated within the Mpukunyoni Tribal Authority and the community is guided by tribal laws, customs and traditional structures. The sub-study results on which this paper draws are part of a larger study, assessing community acceptance and health facility preparedness for the implementation of maternal immunisation programs in urban and rural South Africa funded through IMPRINT—Immunising Pregnant Women and Infants Network. The overall IMPRINT study aimed to understand the knowledge, attitudes and acceptability of maternal immunisation amongst pregnant and non-pregnant women, healthcare providers and community members in rural and urban South Africa [14]. The study design was exploratory, and we used qualitative data collection methods that included in-depth interviews and focus group discussions. Individual interviews were conducted with 28 participants. Six of the participants were interviewed via the telephone later in June 2020 because of the COVID-19 non-pharmacological measures in place at that time. One focus group discussion was conducted with five pregnant women of different age groups. Table 1 gives a description of the study participants. The sample comprised women who were unemployed, school dropouts and students. Topic guides were translated into the local language, isiZulu, and back translated into English. After gaining informed consent, the interviews were conducted in IsiZulu from December 2019 to June 2020. All data collection activities were digitally recorded, transcribed verbatim and then translated to English. We provide the topic guides we used in Supplementary Materials (S1–S5). Study participant description. Interviews were conducted by trained field workers in private settings where the participants felt comfortable. Interviews lasted approximately forty-five minutes to an hour. Interview summaries were written by the fieldworkers immediately after each interview to provide an overview of the interview and the main points raised and to complement the transcription, which took longer to produce. Debriefings between the lead researchers and the fieldworkers were conducted after each interview. Data quality checks were conducted by the facilitators to ensure the completeness and accuracy of transcripts. Participants were given identification numbers; these are used in the presentation of our results to allow readers to distinguish between quotes from different people. Thematic content analysis was conducted manually by two authors (RSC) and (NN), who are experienced social scientists. Data were managed using a framework analysis approach. The theoretical framing of the Health Belief Model (HBM) was used as a guide to identify and group emerging themes related to the acceptability of maternal immunisation. Themes related to HBM constructs were identified through coding and data were copied and pasted into excel sheets according to thematic areas. Indexing (coding) and charting (copying and pasting data according to thematic areas) were carried out simultaneously. The Health Belief Model (HBM) is one of the most widely used theoretical frameworks for understanding health behaviour [15,16]. This model is used to assess intra-personal factors, including risk-related beliefs that may influence individuals’ health decision making [17]. The HBM conceptual framework comprises six constructs that predict health behaviours, namely, perceived susceptibility, perceived severity, benefits to action, barriers to action, cue to action and self-efficacy [18,19]. The HBM focuses on health behaviour and perceptions towards an illness and prevention. For the purposes of this analysis, we used a modified HBM as illustrated in Figure 1. The HBM analytical framework was used as a foundation for our data analysis. The HBM states that people will take action to prevent illness if they regard themselves as susceptible to a disease (perceived susceptibility) and if they believe it would have potentially serious consequences (perceived severity) [19]. In preparing our coding framework, with the HBM as a basis, we observed additional factors that motivated people to disengage in preventive health behaviours beyond those originally specified by the HBM. Social norms have been significant predictors of health behaviours in our study setting and can predict health behaviours towards interventions [20], while susceptibility and the perceived severity of disease were seldom mentioned, because of limited awareness among participants on the diseases that maternal vaccination might prevent. The Health Belief Model, adapted from Rosenstock et al. (1974). Social norms often relate to perceived social pressure to engage or not engage in specific behaviours [21]. Attitudes and cultural beliefs shape individuals’ health behaviour and are strong motivators of behavioural change [22]. Taking these factors into account, we modified the HBM framework to include constructs of barriers to action, perceived social norms and cues to action.

Based on the information provided, the study recommends several strategies to improve access to maternal health, specifically maternal immunization, in rural KwaZulu-Natal, South Africa. These strategies include:

1. Improving the quality of health service delivery: This involves enhancing the training and skills of healthcare providers to ensure they can provide high-quality care to pregnant women. This includes improving communication, empathy, and cultural sensitivity.

2. Reducing waiting times and distance to health facilities: Measures should be implemented to reduce long queues and improve access to health clinics in rural areas. This can be achieved by increasing the number of healthcare facilities or mobile clinics, as well as improving transportation options for pregnant women.

3. Ensuring a consistent supply of immunization vaccines: The issue of vaccine stockouts should be addressed by improving the supply chain management system. This includes regular monitoring of vaccine stocks, forecasting demand, and timely procurement and distribution of vaccines.

4. Increasing maternal knowledge: Targeted educational campaigns should be developed to raise awareness about the benefits of maternal immunization and address misconceptions or lack of knowledge. This can be done through community engagement, health promotion activities, and the use of culturally appropriate communication channels.

5. Engaging with traditional customs and structures: Collaboration with community leaders, traditional healers, and other influential figures is important to promote the importance of maternal immunization. This can help address cultural beliefs and practices that may hinder vaccine acceptance.

By implementing these recommendations, it is expected that access to maternal health, specifically maternal immunization, can be improved in rural areas of KwaZulu-Natal, South Africa.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health is to address the barriers identified in the study, such as traditional customs and institutional barriers. This can be done through the following strategies:

1. Improve the quality of health service delivery: Enhance the training and skills of healthcare providers to ensure they can provide high-quality care to pregnant women. This includes improving communication, empathy, and cultural sensitivity.

2. Reduce waiting times and distance to health facilities: Implement measures to reduce long queues and improve access to health clinics in rural areas. This can be achieved by increasing the number of healthcare facilities or mobile clinics, as well as improving transportation options for pregnant women.

3. Ensure a consistent supply of immunisation vaccines: Address the issue of vaccine stockouts by improving the supply chain management system. This includes regular monitoring of vaccine stocks, forecasting demand, and timely procurement and distribution of vaccines.

4. Increase maternal knowledge: Develop targeted educational campaigns to raise awareness about the benefits of maternal immunisation and address misconceptions or lack of knowledge. This can be done through community engagement, health promotion activities, and the use of culturally appropriate communication channels.

5. Engage with traditional customs and structures: Collaborate with community leaders, traditional healers, and other influential figures to promote the importance of maternal immunisation. This can help address cultural beliefs and practices that may hinder vaccine acceptance.

By implementing these recommendations, it is expected that access to maternal health, specifically maternal immunisation, can be improved in rural areas of KwaZulu-Natal, South Africa.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, a mixed-methods approach can be used. Here is a suggested methodology:

1. Quantitative data collection: Conduct a survey among pregnant women in rural KwaZulu-Natal to gather information on their access to maternal health services, including maternal immunization. The survey should include questions related to barriers identified in the study, such as traditional customs, institutional barriers, waiting times, distance to health facilities, vaccine stockouts, and maternal knowledge. The survey can be administered through face-to-face interviews or mobile data collection tools.

2. Qualitative data collection: Conduct focus group discussions and in-depth interviews with pregnant women, healthcare providers, community leaders, and traditional healers to gain a deeper understanding of the barriers and facilitators to accessing maternal health services. These discussions can explore the impact of the recommended strategies on improving access to maternal health.

3. Data analysis: Analyze the quantitative data using statistical methods to determine the prevalence and significance of the identified barriers. Conduct thematic analysis of the qualitative data to identify common themes and patterns related to access to maternal health services.

4. Simulation modeling: Develop a simulation model using the quantitative and qualitative data to estimate the potential impact of the recommended strategies on improving access to maternal health. The model can simulate different scenarios, such as increasing the number of healthcare facilities, reducing waiting times, improving transportation options, and implementing targeted educational campaigns. The model should consider the interplay between different factors and their potential synergistic effects.

5. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the simulation model and explore the potential impact of variations in key parameters, such as the effectiveness of the strategies and the population coverage.

6. Policy recommendations: Based on the findings from the simulation model, provide evidence-based policy recommendations to stakeholders, including government agencies, healthcare providers, and community leaders. These recommendations should highlight the strategies that are most likely to have a significant impact on improving access to maternal health services.

By following this methodology, researchers can gain insights into the potential impact of the recommended strategies and inform decision-making processes to improve access to maternal health in rural KwaZulu-Natal, South Africa.

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