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Abstract
Objective The study sought to explore the perspectives of vaccinators on the health system factors that impacted the COVID-19 vaccination campaign.
Design The study employed an exploratory-descriptive qualitative design. Key-informants’ interviews were conducted using semi-structured guide to gather the data. Thematic analysis following the steps of Braun and Clark was conducted using ATLAS.ti software.
Setting The study setting was the Cape Coast Metropolis where the Central Regional Health Directorate is located. The Directorate initiates and implements policy decisions across the region. It is also the only metropolis in the region that recorded about 5970 of the total COVID-19 cases recorded in Ghana.
Participants Eleven vaccinators who had been trained for the COVID-19 vaccination and had participated in the campaign for at least 6 months were purposively sampled through the Regional Public Health Unit.
Results Four themes were derived from the data after analysis; ‘vaccine-related issues’; ‘staffing issues’; ‘organising and planning the campaign’ and ‘surveillance and response systems’. Subthemes were generated under each major theme. Our results revealed the health service promoted the COVID-19 vaccination campaign through public education and ensured access to COVID-19 vaccines through the use of community outreaches. Also, the health service ensured adequate logistics supply for carrying out the campaign as well as ensured vaccinators were adequately equipped for adverse incidence reporting and management. Dissatisfaction among COVID-19 vaccinators attributed to low remuneration and delays in receiving allowances as well as shortfalls in efforts at securing transportation and a conducive venue for the vaccination exercise also emerged. Other challenges in the vaccination campaign were attributed to poor data entry platforms and limited access to internet facilities.
Conclusion This study highlights the health system’s strategies and challenges during the COVID-19 vaccination campaign, emphasising the need for critical interventions to prevent low vaccination rates.
- organisation of health services
- qualitative research
- public health
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
The design allowed for an in-depth exploration of the research topic which has not been widely studied.
Possibility of social desirability bias in highlighting participants’ own perceptions of the health systems factors affecting the success of the campaign could not be excluded as all the participants were health professionals.
The study methodology relies on a small sample size and thus the findings are not generalisable; rather it is unique to context and population with similar dynamics as the Cape Coast Metropolis.
Introduction
The COVID-19 pandemic has had a devastating impact on the world. The high infectivity of the COVID-19, severity of the morbidity and high case fatality rate during the early stages of the pandemic was unsettling.1 This prompted several interventions to halt the spread of the COVID-19 and to reduce its infectivity.2 Prominent among these interventions was the development of vaccines against COVID-19.3 4 To ensure the development, production and equitable distribution of the vaccines globally, the WHO and its partners initiated the COVAX facility which culminated in vaccines such as Pfizer-BioNTech, Sputnik V, Moderna, Sinopharm and AstraZeneca.5
Ghana became the first country in Africa to receive the COVID-19 vaccines through the COVAX initiative and the African Union in February 2021.6 7 Subsequently, vaccination campaigns were rolled out throughout the country under the auspices of the Ministry of Health (MoH) and its agencies on 1 March 2021 and by 31 March 2023, a total of 22 384 226 vaccine doses has been administered.8 The MoH began its vaccination drive in line with epidemiological considerations based on the risk of the population while leveraging on the experiences gained through existing immunisation programmes.5 Health workers, older adults and persons with pre-existing conditions that put them at high risk for severe COVID-19 complications were prioritised.9
Although, great strides were made in the country’s vaccination drive, the campaign was not without challenges. Several studies reported vaccine hesitancy that was mainly underscored by misinformation, and myths.10 11 Prior to the rollout of the nationwide vaccination campaign, the vaccine hesitancy rate was recorded at 60% among the general population12 but this reduced to 23.8% by June 2021.10
To ensure a successful vaccination campaign, WHO outlined elements that the health system had to implement. These include staff training and capacity building, planning organising and supervision, demand generation, monitoring, surveillance and response systems, supply chain systems and cold chain, storage and handling.13 However, until now, the few studies that have reported on these health system factors that impacted the vaccination drive have focused on the attitudes of health workers toward vaccination.14 15 This study, therefore, departs from earlier studies by seeking to explore the perspectives of vaccinators about the health system factors that impacted the COVID-19 vaccination campaign.
Methods and materials
Study design and setting
A qualitative exploratory design was employed to unearth the health service factors that impacted the vaccination campaign in the Cape Coast Metropolis of Central Region of Ghana. This method was deemed necessary as a comprehensive review of the literature revealed a dearth of evidence on this phenomenon in the Ghanaian context. The study was set in Cape Coast Metropolis because it houses the seat of the Central Regional Health Directorate, where policy decisions are initiated and implemented. Also, of the 1 693 530, total target eligible individuals for vaccination; 854 206 persons representing about 50% had been fully vaccinated by February 2023.16
Population and sampling procedure
The study population was vaccinators involved in administering the COVID-19 vaccine during the pandemic. To be eligible, the vaccinator should have been formally trained for COVID-19 vaccination and participated in the campaign for at least 6 months. The Regional Disease Control Officer was contacted to inform staff about the study. Fifteen eligible participants were contacted. Following discussions with the vaccinators, 11 participants were purposively sampled. Reasons for decline included work schedule and load, while one participant was unavailable at the time scheduled for the interview.
Data collection
Data collection took place between January and February 2023. A total of 11 key informants’ interviews were conducted in English using a semi-structured guide. The guide was designed following a review of literature. The elements outlined by WHO to influence strong immunisation programmes including staff training and capacity building, organising, planning and supervision, monitoring, surveillance and response systems, supply chain management, and cold chain, storage and handling were reviewed and adapted to guide the development of the questions on the interview guide.13 Three pilot interviews were conducted to improve the interview guide but were not included in the final analysis. After that, three members of the research team conducted and audio-recorded interviews independently for all participants to ensure investigator triangulation.17 The interviews were conducted at the participants’ convenient time and place, lasting between 30 and 40 min. A total of 11 interviews were conducted based on data saturation.
Data management and analytical approach
Data collection and analysis were conducted concurrently as is typical of qualitative research.18 To begin, the interviews were transcribed verbatim. Each transcript was then assigned an identity number to anonymise them. The audio-recordings were saved on a password protected computer and are being kept for 5 years and then will be deleted permanently.
Then, thematic analysis following the steps of Braun and Clark16 was done using ATLAS.ti software V.8.4.4. The researchers familiarised themselves with the data by reading the transcripts and listening to the audio recordings severally. The researchers conducted the initial open coding by labelling the meaningful units as codes to determine patterns in the data. The codes were then grouped based on the patterns identified to generate categories.
Subsequently, the team met to confirm the common themes and subthemes that participants emphasised. The codebook was then applied to the text to code all transcript by the principal investigator and reviewed by the other team members. The findings were then organised by themes and subthemes derived from the inductive analysis having in mind the research objectives and questions.
Rigour of the study19 was safeguarded through member checking. An audit trail was ensured to achieve confirmability and dependability. Transferability was achieved by describing in detail the context of the study as well as participants’ experiences to make it meaningful to readers.
Patients and public involvement
The research instrument was finalised following clarifications and suggestions from the disease control officers in the Regional Health Directorate and other nurses who participated in the pilot study. Member checking was also conducted to ensure that the initial themes generated from the study aligned with the thoughts of the participants before the findings were finalised.20
Results
Sociodemographic characteristics of participants
A total of 11 vaccinators participated in the study. Their ages ranged from 23 to 41 years old. Majority of the participants were nurses while the remaining were disease control and public health officers. The minimum qualification was certificate with several others holding a Bachelor’s degree. All the participants had been trained prior to their participation in the COVID-19 vaccination campaign (table 1).
Sociodemographic characteristics of participants
Emergent themes
Four themes were derived from the data after analysis; ‘vaccine-related issues’; ‘staffing issues’; ‘organising and planning the campaign’ and ‘surveillance and response systems’. Subthemes were generated under each major theme (figure 1).
Themes and subthemes.
Theme 1: vaccine-related issues
Vaccine availability, diversity and client preferences
All the participants indicated vaccine availability during the initial stages of the vaccination campaign. Most of the participants reported that the health service supplied them with different brands of the vaccine to administer to the clients.
In our facility, we had AstraZeneca from India, Sweden and UK, Moderna, Johnson and Johnson, and Pfizer. So, we were vaccine-rich. (V07, public health nurse)
The availability of the different brands afforded the health workers to meet the preferences of their clients in relation to the brands of the vaccines that they desired. These choices were mainly associated with the number of doses that the clients had to receive to be fully vaccinated.
There are also those [clients] who will tell you, they just want a single dose, such people are given the Johnson and Johnson. There are others who also make their preferences and we have to give them what they want (V04, field technician and disease control)
However, the narratives revealed that as the vaccination campaign progressed and the rate of acceptability increased, there were incidents of stock-out of the initial brands of the vaccines that they administered during the early stages of the vaccination campaign.
We have run out of stock for one particular vaccine called Moderna. As we speak now, some have taken the first dose of that vaccine and waiting for the second and yet we don’t receive them anymore. That makes them complain anytime we get to the communities. (V01, nurse)
This shortage therefore resulted in some people who had received the first doses refusing to accept any other vaccine and so remaining partially vaccinated.
Some of the people did not want to mix the vaccines even though we told them it was ok to take it. So, they remained. (V10, disease control officer)
Vaccine safety concerns
The participants indicated that they were reminded of their responsibility to ensure that vaccines were safe to be administered. For several of them, their previous experiences in handling other vaccines were reinforced through the training of vaccine safety.
The Disease Control Officer explained to us our responsibility in keeping the vaccine safe to use and effective. You see, we have been doing this with other vaccines. So, it was just a refresher something [training] before we started our work. (V09, community health nurse)
Although some participants reported safe and active vaccines for the COVID-19 vaccination campaign, one person shared an experience of identifying an inconsistency in the batch number of the vaccine, thereby raising an issue of vaccine manufacturing concerns and safety. He said:
There are instances that we have discrepancies with the batch numbers we had on the vaccines and what they have in their system. At such points it becomes challenging try to tally them. You see it’s about the patient’s safety and striving to avoid a very avoidable adverse incident. (V05, field technician and disease control)
Theme 2: staffing issues
Motivation for staff retention
Most of the participants reported lack of motivation to remain in the campaign.
… There is no motivation in this campaign. This is our greatest challenge. (V09, community health nurse)
The lack of motivation was mainly attributed to the dissatisfaction with the financial remuneration that was paid to the vaccinators and their team members.
There are times, we will be told that money has been given to our leaders to be given to us, yet it will never trickle down to us. (V06, field technician and disease control)
Another concern of the participants was the delay in remuneration for the vaccination. This reportedly demotivated some of the staff and contributed to their attrition. One participant said:
They should also work on the wages for the vaccination team. The payment always delays which demotivate the team members. (V03, public health officer)
Vaccinator–client ratio
Participants indicated that several staff were recruited and trained prior to the commencement of the vaccination campaign. It was however evident from the narratives that the vaccinators were inadequate to cover the number of clients who presented to receive the vaccination.
The people we are serving are a lot, as against the few staff we work with. Sometimes, most of them complain about the time and the fact that, they have other important things doing elsewhere and cannot waste all the time in a queue. Meanwhile, it is no fault of ours too. (V11, community health nurse)
The narratives revealed that this inadequate number of vaccinators could be attributed to high attrition among the health workers during the vaccination campaign.
… Most of our team members resigned from the campaign. (V02, nurse)
It was evident that this attrition also impacted the campaign. The low vaccinator numbers contributed to delays during the vaccination process and further caused disgruntled clients.
Theme 3: organising and planning the campaign
Promoting access
From the narratives, the COVID-19 vaccination campaign was organised on outreach bases within reach of their clients. This reportedly enhanced accessibility and promoted uptake of the vaccination.
Like all the vaccinations that we do in Ghana, the COVID vaccination too was done in the community. We [vaccination teams] were grouped and asked to go to specific locations. Some were stationed in churches, mosques and even in schools. So, it made it easy for people to just take it [get vaccinated]. (V07, nurse)
It was evident that although this outreach approach to the campaign was strategic, locating venues that were convenient for the participants and vaccinators was challenging.
One said:
Our major challenge now is with the space for the vaccination team. Initially, we were working at our office where we treat the normal health issues. But since COVID-19 is a different case, we needed a better place to be able to serve the clients well but [we] haven’t actually gotten what we desire. So, for now, we are hanging around this area until we get a new place (V05, field technician and disease control)
The participants reported demands for money for the venue, which was not within the purview of the vaccinators but caused frustrations and delays.
At the community level, getting a space to setup and start the operation is a problem. Any space you request for, the community members will be asking for money before allowing you to use that, including the information centres at the various communities. (V09, community health nurse)
Availability of logistics
All the participants’ narratives revealed availability of consumables for the actual vaccination. This according to them made the process easy and successful.
We [vaccinators] were given adequate syringes, vaccines, and everything we need for the campaign. I don’t remember a time when there was ever a shortage at my end … (V08, nurse)
The logistics for data entry for surveillance purposes were also adequately provided for the vaccinators.
We were given an iPad to input the records of the people we vaccinated. Each team had their own. So that was not a problem. (V10, disease control officer)
However, the participants revealed that, the campaign was impacted by transportation challenges. Participants revealed challenges obtaining transportation for the vaccination campaign including transportation of vaccines and the health staff to the venues for the campaign.
Most often the office van we use are unavailable at the time of the need. When we call, they complain about the fuel and its non-availability. (V01, nurse)
For other vaccinators too, the absence of transportation caused them to incur cost and this contributed to some participants intentions to quit or absent themselves from the scheduled vaccination exercise.
There are times that we need to use our own monies for the transport fares to the various communities when we are called. So, in times we don’t have the means, we put our logistics down until we find money on our own to visit such places. (V04, field technician and disease control)
Public health messaging
The participants in this study asserted that efforts were made to effectively educate the general public about the importance of the vaccination. Education on the vaccine’s safety, efficacy and importance in controlling the spread of COVID-19 was reported.
Initially, it was a difficult task because of the vaccine hesitancy but gradually with continuous and periodic health education … we do sensitization of the masses, so with that we have realised that some perceptions have been worked on, some people have changed and we have fairly quiet a number of people enrolling in for the vaccination. (V02, nurse)
From the narratives, the strategies for conducting the health education were varied. These included the use of mass media like the television and radio broadcast as well as engaging members of the public individually.
We [health workers] used to go the FM stations and the television stations to speak about it [vaccines], and how it works and the importance of the vaccine, but yet still now it’s the hesitation, it is not force. We also encourage people to take the vaccine when they come to the hospital (V07, public health nurse)
In spite of the public messaging on the vaccination, there were experiences of vaccine hesitancy among the population. There were several narratives that suggested that mobilising community resources to promote awareness by the health service was a viable solution.
… In addition to the education being done at the Radio and TV stations, I think community announcements, the traditional leaders [also talked about it]. For instance, when the chiefs accept; the community members also accept. That is how it is. (V08, nurse)
Several others suggested the use of health experts by the health system to educate the public about the vaccines will further enhance vaccine acceptability.
The reason for their refusal has always been on a misinformation on the media, that the whites are in with the vaccine to kill us and a whole lot of funny stories … Recruit people in the field of health information or the experts to educate the masses because behavioural change takes time. (V08, nurse)
Theme 4: surveillance and response systems
Bane of data entry
Several of the participants expressed challenges with capturing the records of the people who had been vaccinated. These challenges were mainly attributed to website challenges and access to internet required to synchronise data.
Inconsistent nature of the website does not allow us to do a swift data entry. (V07, public health nurse)
This affected the ability of the vaccinators to synchronise their records of their clients to that of the server and created a backlog.
We also have challenges with data to sync our information to the main server. That is why most people complain about their details not being found in the system even though they have been vaccinated. (V02, nurse)
This unsuccessful data entry challenges impacted the clients and required interventions of the health service managers in some instances. One participant said:
The barcode [QR Code] on the COVID vaccination cards we were asked to issue were not linked to the main server too. Because of that, when any of such client wants to travel outside the country, their details might not be found in the system when they enter their names/scan the code at the airport. In such moment, our Head of Department needs to call the offices at the airport and talk with them before sometimes things can be settled. (V10, disease control officer)
Adverse incidents reporting and management
Participants indicated awareness of a protocol for adverse incidence reporting. For most of them, this information was shared with the clients after each inoculation.
We were told to tell every client about the signs of adverse reactions after getting the vaccine. They [Health Service] wrote telephone numbers behind the vaccine cards. So, we pointed it out to the clients to call when something happened after taking the vaccine. (V01, nurse, 9 months as vaccinator)
Other participants also intimated knowledge of a structured referral pathway for adverse incidence management.
With the client, all we do is to calm him or her down and educate them on the side effects of immunization and the fact that we have different immune reactions with different vaccines. In such moments when the person calms down, then we take him or her through the process which can help take off the effect by referring him or her to the doctor for check-ups and treatment. (V08, nurse)
Discussion
The study found that vaccines were available at the start of the COVID-19 vaccination programme. This could be attributed to Ghana being a beneficiary of the COVAX facility and the African Union initiative to promote equitable distribution of vaccines globally,5 as well as donation from other developed countries.21 However, as vaccine acceptancy increased, stockout of selected vaccines occurred. These stockouts were attributed to challenges associated with lapses in procurement of vaccines by the government.22 Consequently, the shortage resulted in the refusal to accept other types of vaccines as a second dose and contributed to the 42.1% of the population being partially vaccinated as of March 2023.23
This study found dissatisfaction among health workers who were vaccinators for the COVID-19 vaccination campaign. The dissatisfaction was attributed to low remuneration, and delays in receiving allowances. This dissatisfaction contributed to staff attrition which further resulted in inadequate numbers of vaccinators to attend to vaccinators on time resulting in long waiting times for vaccination. Although this finding seems unique to this study, several studies have report the role of motivation in retention among health staff.24 25 Similarly, Poon et al intimated that issues of organisational trust and support contributed to the health workers turnover intentions during the pandemic.26
Congruent to other studies elsewhere,27 28 this study found that the MoH and its agencies leveraged on experiences of existing immunisation programmes and adopted a ‘service at your door step’ approach by setting up vaccination centres in various communities and organisations to improve access to the COVID-19 vaccines. This approach improved service uptake as barriers such as cost of transportation and distance to be covered were all addressed.28 In spite of this success, the study found shortfalls in the Ministry’s effort at community engagement as securing a conducive venue for the campaign was identified as a problem in this study. This could have easily been addressed with the existing arrangements of the Community-based Health Planning and Services policy where communities are seen as a social capital and their full participation in the planning of health-related activities have been successfully implemented.29
In this study, the health services’ preparedness for the vaccination campaign especially with the provision of consumables, personal protective equipment and other equipments for data entry resonated. This could be attributed to the countries procurement efforts,30 as well as donations from international organisations such as UNICEF.31 On the other hand, the study also found that there were planning lapses for some aspects of the vaccination campaign such as transportation and issues related to venues for outreaches which negatively affected the campaign.
The findings revealed that the health system intensified health education about the vaccine’s safety, efficacy and importance in controlling the spread of COVID-19. This finding corroborates that of other countries.32–34 This activity reportedly improved citizens’ knowledge about the vaccine and its benefits and consequently contributed to vaccine acceptancy.35 The study findings further points to the need to engage community opinion and religious leaders to promote the education about COVID-19 vaccination as there are still people who are hesitant.10
Limitations and strengths of the study
The researchers acknowledge some possible limitations of the study. First, the possibility of social desirability bias cannot be overlooked as the participants at the time of the study were all employed by the health system and could therefore report perceptions that could be prejudiced or put their employers in a positive light. Also, the possibility of contextual bias cannot be excluded as the study was set in a single metropolis. To address this, the setting was duly described to allow for transferability of the study if necessary. Furthermore, the study methodology relies on a small sample size and thus the findings are not generalisable; rather it is unique to context and population with similar dynamics as the Cape Coast Metropolis.
The study’s strength lies in its novelty and the use of exploratory design to allowed for generating new knowledge in on a phenomenon that has limited empirical studies being conducted.
Conclusion
This study provides valuable insight into the strategies employed by the health system and the challenges that accompanied the COVID-19 vaccination campaign. It highlighted both the positive aspects of the campaign such as public education and logistics supply as well as challenges including dissatisfied staff, delayed remuneration and infrastructural limitations. The findings suggested that a successful vaccination campaign requires not only effective promotion and planning but also addressing human resource factors.
The findings can inform strategies for improving vaccination coverage and uptake in the study area and potentially in other similar settings. The findings are also valuable for improving the overall success of vaccination campaigns, which is essential for controlling the spread of the virus and ending the pandemic.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and approval for the study was granted by the University of Cape Coast Institutional Review Board (UCCIRB/EXT/2022/16). The study adhered to the ethical principles proposed by Declaration of Helsinki of Scientific Research for the conduct of research with human participants. All personal identifiers were removed from the data and pseudonyms were used to ensure confidentiality and anonymity. Both written and oral informed consents for participation and publication of the findings were obtained from the participants.
Acknowledgments
The authors extend many appreciations to Mr Enoch Koomson at the Regional Health Directorate, Central Region for his assistance in reaching eligible participants and to all the health workers who participated in the study.
Footnotes
Contributors SAAA, JOA, DKS and DO-Y designed the research. SAAA, JOA, GOB, DB-D, AAD and DFA collected the data, analysed and drafted the manuscript. DB-D, SAAA, DO-Y, DKS, GOB, AAD and JOA reviewed the manuscript for important intellectual content. SAA and DO-Y responsible for the overall content as the guarantor. All authors have read and approved the final manuscript.
Funding The study was sponsored by the the Directorate of Research Innovation and Consultancy, University of Cape Coast, Ghana.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.