No | Findings by steps | Key actors | Level of the surrounding environment | |
C | S | |||
A. Knowledge, awareness and belief | ||||
1 | Caregivers’ fears of injection and AEFI overpower the perceived benefits (health, disease prevention). | √ | √ | Individual |
2 | Media can also increase vaccine hesitancy; for example, negative news related to vaccination (AEFI, death, halal status of the vaccine) or hoaxes disseminated through social media. | √ | √ | Individual, community |
3 | Halal–haram issue was mentioned, even though no exact clarification is available. The halal–haram issue is also coupled with many different issues (AEFI, fear of injection, etc) | √ | √ | Community |
4 | Many caregivers with no ID card admitted that they had concerns around visiting village health post and Puskesmas. They claim not to know that vaccination services are available for every child. | √ | √ | Family |
5 | Influence from the family (core and extended) may lead to the discouragement of vaccination. | √ | Family | |
6 | Lack of knowledge could result in health workers not being able to provide the community with adequate information about the vaccination. | √ | Health system | |
B. Intent | ||||
1 | Some homeless caregivers mentioned that they never received the endorsement from the community leaders and stated that this would not result in compliance. | √ | Individual | |
2 | Perception that the MR vaccination programme is only about politics. | √ | Individual | |
3 | Fears among some caregivers that the vaccination campaign is a trial project that can result in child paralysis. | √ | Individual, political system | |
4 | In some areas, there were caregivers who interact less with their neighbours, claiming not to be exposed to vaccination-related conversations. | √ | Individual, community | |
5 | News about counterfeit vaccines or the substances in the vaccine. | √ | Community | |
6 | Gender roles can overpower knowledge. Even though childcare is perceived as the mother’s responsibility, mothers will not disobey their husbands when they do not permit their children to be vaccinated. | √ | √ | Family |
7 | Family tradition affects acceptance. | √ | Family | |
8 | Information also flows between those who are related, even though they do not live nearby. When one family believes you do not have to accept vaccination, they contact their relatives and influence them. | √ | Family | |
C. Preparation, cost and effort | ||||
1 | Conflicting schedules remain an issue and might hamper vaccination. | √ | √ | Individual, health system |
2 | Many farmers (and their children) are not available during the vaccination schedule in a few areas where farming is the main activity. Children usually skip school during these times. | √ | Community | |
3 | Population mobility in urban slums results in hesitancy due to unfamiliarity with the health system among the new residents. The high incidence of urban slum mobility results in data on vaccination targets becoming relatively outdated. | √ | Community | |
4 | Geographical barrier is a factor that decreases vaccine coverage: areas far from the health centres, that cannot roads cannot reachhere access depends highly on the weather. | √ | Community | |
5 | Vaccine storage remains an issue in several locations. | √ | Health system | |
D. Point of service | ||||
1 | Caregivers are afraid of having their children receive multiple injections at the same time or within a short period. | √ | √ | Individual, health system |
2 | The vaccination service at Puskesmas is very crowded, often with longwaiting times. The Puskesmas is also relatively far from caregivers’ homes, involving extra time and costs. | √ | Individual, health system | |
3 | In village health posts, vaccination services are only provided at fixed time points (usually once a month) and highly depend on the midwife’s availability. | √ | √ | Individual, health system |
4 | Higher socioeconomic groups tend to use private providers (creating challenges for recording and reporting), whereas lower socioeconomic groups opt for a public provider. | √ | Individual | |
E. Experience of care | ||||
1 | Previous bad experience (any AEFI, long waiting time, inconvenience during the waiting time (eg, hot weather), absence of informed consent before injection, fear of injection) introduces hesitancy in mothers and children. | √ | √ | Individual |
F. After service | ||||
1 | An unrelated, unfortunate event after the vaccination can be associated with the vaccination and increase vaccine hesitancy. | √ | Individual | |
2 | AEFI impacts vaccine acceptance. Both health workers (trauma) and beneficiaries (rejection) are affected. | √ | √ | Individual |
Source: prepared by the authors from the study data.
AEFI, adverse event following immunisation; C, caregivers; MR, measles–rubella vaccine; Puskesmas, primary health centre; S, stakeholders (healthcare providers, district health office, cadres).