Community Insights to Identify Determinants of Zero-Dose Children in Melanesia: A BeSD Tool Adaptation

Key Takeaways

• Provide incentives and cover transport costs for participants engagement​.
• Allow extended time for data collection processes, especially in rural/remote areas where transport is difficult​.
• Coordinate data collection activities during dry season, under better weather conditions(if possible)​.
• Resource research team to travel directly to remote and hard-to-reach communities to increase access to zero-dose children​.
• Secure additional resourcing to allow for appropriate in-country consultation and coordination with program managers and health care service providers’ schedules.

Background

Between 2019 and 2021, routine immunization coverage for DTP-1 and MR-1 significantly declined across the Melanesian nations of Solomon Islands, Vanuatu, and Papua New Guinea (PNG), leading to an increase in zero-dose children (operationally defined as those who have not received the first dose of the DTP-1 vaccine). The COVID-19 pandemic placed strain on the capacity of health systems, limiting their ability contributing to increased vaccine^(1,2) highlighted the need for research to better understand the context-specific barriers to routine immunization and to develop targeted interventions to reach zero-dose children.

This project, in collaboration with local research teams and ministries of health, assessed the applicability of the Behavioral and Social Drivers of Vaccination (BeSD) tools, developed by the World Health Organization (WHO), to the Melanesian context. The BeSD tools include surveys and in-depth interview guides designed to identify barriers to vaccine uptake among under-immunized and zero-dose children, in addition to offering a framework to inform the design of program interventions⁽³⁾.

Methods 

The BeSD surveys and in-depth interviews were pre-tested and adapted for the local context in PNG, the Solomon Islands, and Vanuatu. Pre-testing involved conducting interviews with participants from urban and rural areas in each country, using both the BeSD tools and UNICEF’s Journey to Health and Immunization (JTHI) Framework. After analysing these initial interviews, the BeSD tools were revised accordingly and used in a second round of interviews.  

Four key participant groups were identified and purposively recruited with the support of ministry of health counterparts in each country:

1. Parents/caregivers of under-immunized and zero-dose children
2. Community and religious leaders
3. Health care workers
4. Immunization program managers

In Solomon Islands, BeSD tools were pre-tested in Tinagulu village and Marau Island in Guadalcanal Province. Adapted BeSD tools were implemented in Barana village, East Honiara and Nahoho and Naboneta villages, Tetekanji, Guadalcanal Province. In Vanuatu, BeSD tools were pre-tested in Mele village and Teoma, Efate and Pele Island, all in Shefa Province. Adapted BeSD tools were implemented in Lowanatom and Lounapkiko villages, Tanna Island, Tafea Province. In Papua New Guinea, BeSD tools were pre-tested in in Goroka and Kainantu in Eastern Highlands Province. Adapted BeSD tools were implemented in Goroka and Daulo, a rural site alongside a national highway.  

Below is a brief overview of the findings based on responses to in-depth interview questions from the adapted tools from each country.   

Findings: Solomon Islands 

Table 1. Participant Characteristics (n=16), Adapted BeSD tools, Solomon Islands 

Individual Concerns

Caregivers, particularly those who gave birth at a health facility, considered routine vaccination to be important, and generally understood that vaccines protect children from diseases. Knowledge of specific diseases appeared to be limited. 

Social Influences

Church and community leaders influenced vaccine decision-making and awareness; while most supported childhood vaccination, a minority did not allow it in their communities. Awareness of routine vaccination services appeared to be less common in remote communities with limited health facility access.  

Mothers were primarily responsible for ensuring their children received routine vaccines. Healthcare workers reported that fathers might refuse vaccination of their child if a male health worker was going to be present, their child experienced previous side-effects, or due to financial constraints. Extended family members often provided caregiving support to enable vaccination. Adolescent mothers were noted by a community leader to be particularly unlikely to vaccinate their children. 

Experiences at the Health Facility

Health workers reported a lack of time to educate caregivers, mostly relying on those mothers who visited health facilities to share reminders with other mothers. Health education sessions were usually delivered once in the morning at health facilities, so caregivers who arrived later in the day missed out. The ‘Baby Clinic Book’ effectively reminded caregivers when to return for future vaccinations, but some caregivers described difficulties understanding it. Health workers reported that language barriers and caregivers’ limited education made it difficult to communicate. Program managers believed that few health workers had the necessary knowledge to explain vaccination effectively. Participants reported that health facilities often experience staff shortages and vaccine stock-outs, which can discourage caregivers. Program managers experienced difficulties monitoring children from mobile families. 

Access

Access barriers formed the major barrier to vaccination. Travel to health facilities was reported to be arduous, prohibitively expensive, and weather dependent, and caregivers often faced opportunity costs when taking their child to a health facility. Mothers were primarily responsible for vaccinations, with few fathers assisting with transportation. Some mothers described not feeling comfortable travelling alone to the health facility. 

Findings: Vanuatu 

Table 2. Participant Characteristics (n=13), Adapted BeSD tools, Vanuatu 

Individual Concerns

Caregivers were motivated to vaccinate their children to protect their child’s health. Many had a limited understanding of how vaccines work and the diseases they prevent, and some mothers expressed concern about vaccine side effects. 

Vaccination Communication

Healthcare workers advised caregivers about routine vaccination at birth and during follow-up visits and used the ‘Child Health Book’ for scheduling and reminders. In remote areas, vaccine awareness was limited, and information was typically shared informally by community members. Mothers often needed to persuade fathers of the importance of vaccination, and some had reportedly encountered undue stress or physical aggression if their child experienced side-effects. Community leaders acted as important liaisons between healthcare workers and community members.  

Healthcare workers believed that health education and vaccine communication activities could help address vaccine refusal due to religious or cultural beliefs. They also noted some communities resisted these efforts, and caregivers, especially those with lower education levels, had difficulty understanding messaging. Previous health education programs were reported to have had low attendance, especially from younger mothers.   

Experiences at the Health Facility

Limited human resources impacted vaccination at health facilities. Program managers noted that inadequate staff training, coupled with high turnover rates, can hinder program effectiveness. A lack of cold chain infrastructure and monitoring systems meant that stock-outs were also common.  

Public Health Surveillance

Current surveillance systems were described as inconsistent. Large catchment areas, mobile and displaced populations, and incomplete records complicated data collection efforts.  

Access

Travel was the major reported barrier to accessing vaccine services, with caregivers experiencing high costs, long journeys, and unpredictable weather conditions. This could often lead to mothers attending the first vaccine appointment but not follow-up visits. Poor road conditions limited outreach, while funding constraints have impacted outreach efforts since the COVID-19 pandemic. Some health facilities have also been affected by natural disasters, including recent cyclones, impacting health care workers’ ability to provide services. 

Findings: Papua New Guinea

Table 3. Participant Characteristics (n=15), Adapted BeSD tools, Papua New Guinea 

Individual Concerns

Caregivers were positively influenced by an understanding that vaccination is important for protection against disease, including general illness. What most prevented motivated caregivers from vaccinating their children were more practical issues of opportunity costs and transport expenses, along with ease of accessibility to the nearest health facility. There were general concerns about the side effects of vaccination raised by mothers/caregivers and discomfort and the sadness they felt when their children experienced vaccine side effects. However, this was also coupled with mixed sentiments of it being ‘bad’ and ‘good’ – the ‘good’ identified as being protective and for the safety of children, the ‘bad’, the side effects experienced.  

Social Influences

Family, friends, and community leaders influenced caregivers both positively and negatively toward getting vaccinated, as did religious leaders/church denominations. Beliefs associated with some religious doctrines, along with rumour and conspiracies associated with mis/disinformation about the effect of vaccines, negatively influenced vaccine uptake. Husbands in rural areas were seen to have the most influence in providing permissions, a particularly cultural gender norm within the rural participant group, which was not as prominent in urban settings.  

Experiences at the Health Facility

Mixed experiences at the health facility (both positive and negative) did not significantly influence caregivers’ decisions about vaccine uptake. Health care workers expressed the workforce capacity and limited resources as a main concern and factor in the full delivery of services – this included systemic issues from the national government level having an impact on service delivery, specifically the timeliness of supply chains and vaccine stocks. There were perceptions that ‘educated’ vs. ‘uneducated’ mothers/caregivers respond differently due to their ability to understand (or not) vaccine health education information. Some health care workers implied that ‘uneducated’ caregivers are less likely to understand information and this negatively impacts uptake.  

Rural Communities

There was strong concern that populations in rural areas have the most difficulty accessing vaccine services, and incur the highest transport/opportunity expenses, including extended stay with relatives, particularly those travelling from remote/inaccessible locations, where no road networks exist. Community leaders were reported to be integral at a community program level with the most local context knowledge and greatest ability to positively influence mother/caregiver engagement with services. These influencers could be utilized more across immunization programs to support vaccine rollout.  

Resource Limitations

Program managers identified workforce and resource limitations as barriers to full rollout of immunization programs. It was identified that having more robust health education and awareness sessions with community could encourage uptake in conjunction with delivering services directly to houses (beyond facility, mobile clinics or patrols) which could be strengthened if workforce and resource limitations are addressed i.e. identified manpower, transport & logistics challenges.   

References

1. Newland, J., et al. “COVID-19 and Its Impacts on Primary Health Services and Public Health Infectious Disease Programs in Papua New Guinea”. PNGIMR and UNSW, 2022, Goroka and Sydney. DOI: http://doi.org/10.26190/6mhp-gc18.
2. Choi, Y., et al. “Identifying Vaccine-Hesitant Subgroups in the Western Pacific Using Latent Class Analysis.” npj Vaccines, vol. 10, no. 29, 2025, https://doi.org/10.1038/s41541-025-01067-3
3. World Health Organization. “Behavioural and social drivers of vaccination: tools and practical guidance for achieving high uptake”. World Health Organization, 2022, https://iris.who.int/handle/10665/354459