Healthcare worker and community health volunteer findings.

The analysis of our qualitative interviews with HCWs and CHVs revealed that the overarching themes related to barriers were the lack of HBV-specific knowledge in the community, limited staffing within the health facility, unavailability of a specific budget for vaccine transportation to the health facility, limited availability of HepB-BD outside of immunization days, the lack of outreach to provide timely HepB-BD to children born outside of health facilities or outside of fixed immunization days, and misconceptions on HepB-BD timeliness and contraindications. Facilitators were the lack of vaccine stock-outs as a result of solar-powered refrigerators, the community’s trust in HCWs, and awareness among HCWs about the need for expanded sensitization and knowledge on HBV and HepB-BD. Constructs identified from findings were outlined by the CFIR (Table 2).

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Table 2. Consolidated Framework for Implementation Science Research (CFIR) identified barriers and facilitators from interviews by healthcare workers and pregnant women related to hepatitis B and HepB-BD.

https://doi.org/10.1371/journal.pgph.0001332.t002

Hepatitis B knowledge among healthcare providers.

The range of knowledge about HBV was highly variable among the HCWs interviewed. Doctors knew significantly more about HBV than other health professionals interviewed (e.g., midwives, nurses); however, doctors were less familiar with routine immunization logistics for hepatitis B, specifically who administered timely immunization and where immunization occurred. Most HCWs knew hepatitis B was a “virus that normally affects the liver. Once you receive the vaccine, it will produce antibody against the virus and protect the child from contracting that virus.” However, misconceptions emerged during interviews with several healthcare providers regarding the transmission of HBV. One nurse described, “they usually like to hold the baby, and some of them might be infected with Hepatitis B without having any symptoms. Hence, when they hold the baby, they may infect it.”

Similarly, a CV shared, “if the person that have the disease touch the baby or even the baby inhales it from the carrier, the baby may contract the disease, so you have to protect the baby before going to the village.” A nurse midwife in Adamawa shared misconceptions related to the transmission of hepatitis B as “people can also get it from sweats from a patient link in a vehicle.” A health facility nurse-in-charge in Enugu described, “Hep B is a viral infection. Mosquito can transfer it from person to person.” Other misconceptions emerged regarding hepatitis B being curable. One doctor shared, “hepatitis B is not a death sentence, and it is curable, and equipment for the test should be made available in the health facilities.” Overwhelmingly, health professionals agreed that there is a strong need for hepatitis B education at the community level. The majority of HCWs and CHVs interviewed acknowledged that the most significant barrier to HBV prevention and control is the lack of knowledge associated with the disease.

Challenges with hepatitis B diagnosis and treatment.

Health professionals noted the following challenges associated with the lack of knowledge on hepatitis B: a) costly medication and treatment were unaffordable for many people, b) isolation due to the illness, c) referrals causing people to drop out of care, and d) overwhelming general lack of resources and hospitals that accommodate people living with HBV. The majority of health professionals interviewed noted the lack of knowledge in the community regarding the diagnosis of HBV, “most people having hepatitis B, they are not aware that they have it.” One chief medical officer noted treatment being a significant burden for HBV, describing, “Yes, treatment of hepatitis B infection is not as available, because the medication for it is not as usually accessible, [it’s] very costly… some prefer carrying their infection and wait for the consequences.” Similarly, a doctor shared, “The challenge we have here is that if we test a person and we found out that he has hepatitis, we usually advise or refer. So, the challenge here is that some of them, usually don’t go for their drugs. And after giving their drugs, the fact that the treatment take[s] longer time. Because of poverty, some of them, they will decide to drop the treatment halfway. And as a result, some will lead to dead.” Related to challenges accessing care for hepatitis B, a doctor described challenges with referrals, “Whenever we send them over to go to the state capital to go and get adequate care most of them turn it down due to distance, financial constraint.”A nurse noted symptoms of hepatitis B impacting those living with the disease, “Hepatitis B is a killer disease. Whenever someone is affected, the person will be frequently ill, sometime[s] they present with oedema, abdominal swelling, and sometime[s] they will be irritable.” The lack of resources and infrastructure to manage those living with hepatitis B was further described as “Then you do the fibroid scan which I doubt if there is any place in Adamawa state that has the fibroid scanning machine. Maybe Adamawa German hospital. So, it is actually very cumbersome.”

Challenges with hepatitis B awareness in the community.

Health professionals spoke of the need for increased awareness and sensitization regarding HBV within communities, the need for infrastructure and resources to manage people living with HBV, and the need to spread the word about the importance of immunization. A unique finding identified the lack of a word for hepatitis B within local languages in Adamawa and Enugu, adding to HBV being described by symptoms and causing confusion within the community. One described, “The need is to create awareness at their settlement, at their villages, the mode of transmission, then the basic symptoms and if they have those symptoms, they should present to the hospital as early as possible instead of using local medication, herbs.” Similarly, another doctor spoke about the lack of awareness of their diagnosis among those living with hepatitis B and described, “I have seen a quite a lot of patients with hep-B and to my surprise, most of them are not even aware they have the infection. So, I think there is lack of awareness.” A chief medical officer in Enugu described, “you know the infection is something they don’t know they have, sometimes they might be thinking they’re charmed, sometimes they might be thinking they are charmed by witchcraft in the society.” A nurse discussed the importance of prevention, “We also need to educate people about the importance of the vaccine and how to live in a health[y] way to avoid getting infected. It is good to start since birth, so that we get optimal protection.”

Hepatitis B birth dose availability and access.

All health professionals mentioned that the hepatitis B vaccine was easily available and maintaining the cold chain worked well; many noted that solar refrigerators were very helpful. One physician from Enugu mentioned, “It’s always available, we have solar fridge here. So, the vaccine is always there in the fridge, and somebody is always there.” Similarly, another mentioned, “because the solar is here, at the beginning of the month, we do bring all the vaccines we need for the month. So most often we do not run out of stock.” While most HCWs noted that stockouts of the hepatitis B vaccine have not happened in some time thanks to the solar refrigerators, a few did mention a few occurrences. One described, “The challenge is when the vaccine is out of stock. That is the only challenge.”

Challenges associated with access to HepB-BD for HCW were the costs of transportation and health facility staffing. Similarly, a nurse responsible for immunization services shared, “the only thing, we transport. They don’t give us money for collection of vaccine or anything. Challenges is that maybe their facility is far from the health local government where they do get the vaccine.” HCWs in both Adamawa and Enugu also shared that staffing is a significant challenge, a nurse midwife in Enugu explained, “we don’t have enough workers here, we are understaffed.” Another nurse echoed “we do not have enough staff so that we will be going to outreach to far place from this health center and tell them the importance of that Hep B.”

Challenges with timely HepB-BD vaccination.

The main challenges affecting timely HepB-BD vaccination (within 24 hours of birth) were births outside of public health facilities, misconceptions among HCWs about the timeliness of HepB-BD administration, and the lack of vaccine administration outside of regularly scheduled immunization days. A medical officer in Enugu shared the challenges associated with home births: "Some areas in the urban slums people who patronize the birth attendants, after delivery they don’t get the Hepatitis B [birth dose] because they don’t have it there. So, the attendant nurses who have the knowledge will always refer them to [health] centres where they can receive [it] but sometimes, those women don’t access the vaccine.”

A medical doctor from Enugu emphasized the importance of TBAs and shared, “some [pregnant women] end up in the private sector, some end up in the TBAs area, some don’t even go, they delivery at home. So for those ones that do not have access to government establishment, most don’t hear it.” A nurse responsible for immunization in Adamawa described, “the challenges is like the way I said it before if the women did not deliver at the hospital or they are too far from the hospital and during raining season that time and then they doesn’t know about it.” A CHV in Adamawa shared, “In our Clinic as of now, we are giving hepatitis B within 14 days but if the woman delivered at antenatal health care at immunization date, we give the injection at birth.” Similarly, a nurse mentioned the role of immunization days and stated, “if you don’t deliver at the hospital on that day, please bring in your child during the week for the immunization day and even if she delivers at the hospital and is not the day of immunization, we tell her to come back.” Other HCWs echoed similar sentiments relating to the roles of immunization days. Similarly, a doctor from Adamawa shared, “women who come around to deliver on Wednesdays, Tuesdays, Fridays, Saturdays and the rest of them? So usually what you expect that these ones are not, they may not really get within the first 24 hours.” Another nurse midwife in Adamawa stated that “Women are coming for the vaccine though most come late at 2 weeks, but we emphasize for women to have it at the clinic after birth.”

Hepatitis B birth dose misconceptions.

HCWs agreed that HepB-BD vaccination was important. All of them described that hepatitis B vaccine administration within two weeks of birth is critical, while some noted the importance of administrating HepB-BD within 24 hours of birth. These findings demonstrate a need to expand knowledge about the importance of HepB-BD timeliness. HCWs agreed that there is some knowledge of hepatitis B at the community level, but overall knowledge is limited. Most described the need for improved education, particularly to encourage health facility deliveries rather than home births so HepB-BD can be administered on time. A HCW mentioned, “We keep encouraging [because] prevention is far better than cure so it is better prevented than waiting for when it comes down with the infection at that time the cost will be high.” A nurse mentioned confusion around birth dose and described, “It is important, like [the oral polio vaccine] zero dose, it has no function, but after that zero dose and Hepatitis B one, then, the immunity will now activate and work very well.” Another mentioned avoiding immunization of HepB-BD if there are contraindications, a common misconception about HepB-BD, and shared, “If we notice the baby has no jaundice we give immediately.” Another misconception about HepB-BD administration was described by a community volunteer who shared, “in order to avoid vaccine wastage we normally ask patients to come back on that immunization days… I want them to come together so that they will receive it like at a larger number.”

Hepatitis B knowledge among pregnant women.

Many women reported not knowing much about HBV. However, some had heard of it but remembered a few details about the virus. An individual shared, “From the little I know is that they say that it’s a deadly disease and it’s contacted by through sexual intercourse and also breastfeeding of baby.” A few women did know that hepatitis B “is a disease of the liver,” and others shared that there is “an immunization given to kids. It’s for health purpose.” Others also had misconceptions about HBV and one shared, “I don’t know much, I know it’s a disease of newborn babies that affect them when they are born,” while another stated, “the little knowledge I know about it is that it is a disease that normally treated in pregnant woman during about 3 to 6 months of pregnancy to avoid some sicknesses after childbirth.” Others mentioned they had heard of HBV but described, “it is not in my lineage” or shared, “the little I know about it, is a disease that kills but for now there is no remedy for it.” Overall, there was limited knowledge about HBV and misconceptions about disease transmission existed within the community.

Hepatitis B birth dose understanding and acceptance.

When asked about the HepB-BD, many women mentioned they did not know much about it other than the fact that it is given to children. All women interviewed shared that they would ensure their child would get HepB-BD if their HCWs recommended it. Overall, the women expressed significant trust in their HCWs. One individual shared, “I just told the midwife that she should attend to me that the way that my baby will be okay, that will not have issue on my baby, that anything that you know as you are a mother before me that you can take care of my child, as in I give everything to you.” Interestingly even though women did not know much about HBV, they would still take it “to protect my baby against hepatitis B.” When asked, all women interviewed felt the birth dose was essential and said they would request it from their HCWs after delivery.

Access to hepatitis B birth dose.

Women described the importance of messaging to increase awareness and access to HepB-BD, especially in rural areas or those delivering at home. A woman described the importance of reaching all women, “some people if the[y] give birth at home they don’t use to bring their child for vaccination, so the suggestion I will make here is that if it will be possible it is good for health workers like you to go into the community make awareness tell them the danger that is involved if your child doesn’t have the vaccine.” Similarly, another woman expressed the importance of rural outreach. She shared, “Some people we come but when you have time to come to village square and make the village come out, that some people are coming to address you people on hepatitis B. If it’s the village square everybody will come and hear what you are saying.”

Recommendations by pregnant women.

The pregnant women interviewed overwhelmingly suggested that providing education during antenatal care through health talks could be most effective in improving HepB-BD awareness among women. Many women described how antenatal care was a helpful tool in education and described receiving information on giving birth, baby positioning, signs the body is ready to deliver, and immunizations. A woman said, “Antenatal day, so that’s the best way I suggest that you should come and lecture them about it.” Others suggested using mass media as a strategy to reach a broader audience. Another said, “I suggest that the government should try to give all information on hepatitis B on radio and television, even on, maybe in churches and schools, we announce to them about it.” Others suggested incentives to increase women’s attendance in educational events. A prospective mother shared, “Some will give bag, some will give tissue, and some will give soap. If you give anything that will, even those that will collect bag. Whenever they hear that they will get them something, [they] will want to come out.”

Another woman suggested having print materials at the time of education and added that visuals would help with learning, “that one is included because during that time of education all this flyers now they use to give us example show us all this flyer and also pictures.” A couple of women emphasized the importance of social media and mass media messaging. A woman explained, “I advise that you put it on social media… like on Facebook, and then Instagram. You should make sure they always advertise … all these a radio station, television station for them for people, because, not everybody that go online or have phone to browse, to go on Facebook, and most people even in these rural area, they’d have television, and when they start seeing this hepatitis B vaccine.” Others also suggested expanding awareness at various places where people go, stating that “Yes, they should create awareness at the markets, mosques, and churches.”