Ask Dr Samuel Afari-Asiedu what determines whether a pregnant woman in Ghana accepts a new maternal vaccine, and he does not offer a single answer. He offers four.
Each shapes the decision in a different way and calls for a different response from the health system. As lead of the vaccine demand work package of the Maternal Immunisation Readiness Network in Africa and Asia (MIRNA) Consortium, and a researcher at the Kintampo Health Research Centre, he has spent the project building an evidence base broad enough to capture all four at once. Ghana’s experience of turning that evidence into policy has made it the consortium’s most closely watched example.
Awareness, trust, experience, cost
“There are varied reasons and varied factors that could shape a pregnant woman’s acceptance of a maternal vaccine,” he says. The first is awareness and information. Having heard of a vaccine counts for little unless the information is accurate and delivered in a culturally acceptable manner, one that resonates with the woman and does not read as an instruction handed down from outside. Get that wrong, and even a scientifically sound vaccine can struggle to gain a foothold.
Trust comes second, and Dr Afari-Asiedu is specific about where it needs to sit. Confidence in a particular nurse or midwife is insufficient on its own. A woman also needs confidence in the health system, in the institution delivering the vaccine as much as the individual administering it. A health worker can be personally trusted while the wider system is viewed with suspicion, and acceptance depends on closing that gap. In his presentation he named this as a live concern, observing that women may be “doubting or having trust issues” with the health system itself.
Past experience is the third factor, and arguably the most self-reinforcing. Women who have had positive encounters with the health system before, during a previous pregnancy or through routine childhood immunisation, are more likely to accept a new vaccine when it is offered. Each good experience becomes evidence for the next decision, so the system’s track record with a woman, built visit by visit, matters as much as any single awareness campaign.
The fourth factor is cost, though it is not the cost one might expect. Maternal vaccines are typically free, but that does not make them costless to the woman receiving them. Dr Afari-Asiedu points to the distance, the time and the travel expenses involved in reaching a facility. Where facilities are far from home, these indirect costs can weigh as heavily on a family as any price tag, a reality that echoes the access challenges MIRNA’s health system readiness research has documented across multiple countries.
Listening beyond the clinic walls
What distinguishes Ghana’s approach, in Dr Afari-Asiedu’s account, is the breadth of voices the work package draws on. MIRNA is organised into work packages, and the social and cultural dimension sits with vaccine demand. His team generates data from what he calls relevant stakeholders, a group that extends well beyond pregnant women to include caregivers, community leaders and mothers-in-law, all of whom can influence a woman’s decision.
He illustrates the point with a simple example. A mother who says she is willing to accept maternal vaccines is expressing an individual decision. But the picture widens quickly. “The pregnant woman may be thinking about husband approval,” he explains, “and so we are moving into the interpersonal or the community level of the social ecological framework.”
Mothers-in-law rarely feature in conventional vaccine communication strategies, yet across the MIRNA countries, family gatekeepers repeatedly surfaced as decisive influences on maternal health decisions, from Bangladesh’s findings on the role of extended family belief systems to Nigeria’s data showing that most women needed permission from a male relative before being vaccinated. By building mothers-in-law and community leaders into its stakeholder mapping from the outset, Ghana treats that influence as something to be understood and engaged with, and does not try to work around it.
Three lenses, one decision
The same thinking explains why the team uses three behavioural models together: the WHO’s Behavioural and Social Drivers framework, the socio-ecological model and the 6A taxonomy. “These multiple frameworks are behavioural models that help us to understand why people accept or refuse health interventions,” he told the meeting. Each answers a different question. The WHO framework examines the reasoning behind acceptance, the socio-ecological model shows “where reasoning sits” and at what level, and the 6A taxonomy translates it into policy language.
The reason for using all three is that a mother’s decision operates at the individual, household and health-system level at once, and no single framework captures every layer. “If you look at the issues just from the individual perspective, then we may be missing the health system level factors that we have to pay attention to,” he said.
He also describes the analytical discipline needed to keep the frameworks honest. “When you are applying the frameworks, you may be tempted to force or box everything that is emerging from the data into one of these frameworks,” he said. “But we were cognisant of that, and so we did a lot of deduction and induction coding.” The approach ensures that findings that fit no framework neatly are still heard.
From evidence to policy
Once the evidence is gathered, the work does not stop at description. The team packages and synthesises it in a form relevant to policy discussions, designed to inform the recommendations that policy bodies will eventually make about these vaccines. It is a deliberate exercise in bridge-building, converting field data into something decision-makers can use rather than leaving findings in a report that never reaches the people setting national immunisation policy.
The structure matters because it sharpens the advice that results. “If we are talking about providing counselling, at what level of the system do we need to have this issue addressed?” Dr Afari-Asiedu asks. The aim, he says, is a “policy-facing output” that is relevant to policy discussions and informs how maternal immunisation is implemented.
A track record that speaks for itself
This helps explain why Ghana kept being cited as a model at the Nairobi meeting, even without delivering its own dedicated country presentation. Both Dr Afari-Asiedu and United Nations Children’s Fund (UNICEF)’s Gloria Lihemo held Ghana up as the consortium’s clearest example of research translating directly into policy. The Ghana Health Service’s EPI focal person took part in the user-centred design workshop that shaped the demand research from the very beginning, and the team’s findings were handed to her immediately afterwards and incorporated into Ghana’s national demand strategy. Lihemo described this as proof that demand data can inform national immunisation technical advisory groups and ministries before other evidence is even reviewed, rather than arriving too late to shape the conversation.
Dr Afari-Asiedu has previously cited the country’s experience introducing the RTS,S malaria vaccine as a warning about how quickly misinformation can travel, with rumours spreading widely enough that some health workers themselves refused to allow children to be vaccinated. That episode sits alongside his proposal to reactivate Ghana’s health promotion department, an existing but underused structure mandated to lead health education, as a more sustainable channel for public communication than antenatal care visits alone.
Asked which ecological level deserves the most attention, he said, “All these levels are very important,” he said. “For me, it is important to look at all these levels in trying to address any barriers that may potentially come up.”
Ghana’s contribution to MIRNA is a working model as it identifies the factors that shape a woman’s decision, builds a stakeholder base wide enough to capture the people who influence her beyond the clinic, and commits to converting that evidence into policy quickly enough for it to matter.