Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study

Introduction: Coverage rates for second year of life (2YL) vaccina-tion still lag behind infant vaccination in most settings. We con-ducted a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after in-troducing the second dose of the measles-containing vaccine.Methods: We conducted 26 focus group discussions in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model theory. We conducted a thematic analysis of the discussion using NVivo software. We use Normalization Process Theory to contextualize results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunization schedule fol-lowing 2YL introduction.Results: Routine immunization for infants enjoys resilient demand, grounded in strong community norms despite surprisingly low levels of vaccine literacy. Despite best practices like integration with the established 18-month "weighing visit," demand for 2YL vaccination is still conditional on individual awareness and com-petition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be "too old" to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming "too late."Conclusion: Closing the 2YL vaccination coverage gap will ulti-mately require modifying embedded norms among caregivers and health care providers alike. Time is necessary but not suffi-cient to reach this goal. Progress can be accelerated by increas-ing the level of community and institutional engagement and adapting services where possible to minimize added costs to caregivers of vaccinating older children.