In the world’s largest refugee settlement in Bangladesh, about 900,000 Forcibly Displaced Myanmar Nationals (FDMN), commonly known as Rohingya refugees, continue to face vaccine-preventable diseases despite the established vaccination programs. Understanding the barriers and drivers to childhood vaccination is crucial, and health service providers (HSPs) play a key role in this process. A recent study delved into their perspectives to uncover the challenges and opportunities surrounding vaccination efforts in this setting.

Using the Capability-Opportunity-Motivation-Behavior (COM-B) model for behavior change, researchers conducted a qualitative study involving eight focus group discussions (FGDs) with community health workers (CHWs) and vaccinators from selected camps with high or low vaccination coverage. Eleven in-depth interviews (IDIs) were also carried out with government and NGO representatives engaged in strategic roles. 

The knowledge and communication skills of HSPs emerged as both barriers and drivers to vaccination efforts. Vaccinators from high coverage camps demonstrated better knowledge of vaccination rates and coverage, compared to their counterparts in low coverage camps, who often lacked accurate data. Generally, the participants understood the purpose of vaccination, though CHWs and vaccinators in high coverage camps provided more specific information on vaccine-preventable diseases (VPDs).

Several systemic barriers were identified, including the use of paper records (tally sheets) due to the absence of a fully functioning electronic information system, making it challenging to monitor vaccination delivery accurately. High workloads, difficult working conditions, and inconsistent salary payments for CHWs and vaccinators further complicated vaccination efforts. While vaccines were generally available, with a reliable cold chain, occasional shortages followed vaccination campaigns.

Vaccination cards were another critical component of the process, serving as reminders for caregivers. However, inconsistencies in their distribution and instances of caregivers losing the cards led to missed vaccination appointments. Mobilising caregivers proved to be an essential task for CHWs, who often conducted household visits to remind families of upcoming vaccination appointments. Yet, reaching vaccination sites remained a challenge due to long distances and challenging terrains in the camps.

Coordination and communication among frontline HSPs varied, with CHWs from high coverage camps reporting good collaboration, while those in low coverage camps faced frustrations over a lack of shared information from vaccinators. The importance of community leaders—majees (block leaders), imams (religious leaders), and Camp-in-Charge—was widely recognized, as they played a crucial role in promoting vaccination.

The study highlighted that improving childhood vaccination coverage in the camps requires addressing context-specific barriers such as enhancing collaboration, strengthening the health workforce, and using incentives. Addressing caregivers’ mistrust, which stems from historical and social backgrounds, demands targeted communication and campaigns that consider the Rohingya community’s unique experiences. 

Reference: 

Reda S, Weishaar H, Akhter S, Karo B, Martínez J, Singh A, et al. Health service providers’ views on barriers and drivers to childhood vaccination of FDMN/Rohingya refugees: a qualitative study in Cox’s Bazar, Bangladesh. Frontiers in Public Health [Internet]. 2024 Jul 9;12. Available from: https://doi.org/10.3389/fpubh.2024.1359082