Examining perceptions, social, and policy factors influencing hepatitis B birth-dose vaccine uptake: a PEN-3 cultural model mixed-methods study of healthcare workers in Nigeria

Introduction: The timely administration of the birth-dose hepatitis B (HepB-BD) vaccine is recommended by global and national guidelines to effectively prevent perinatal transmission. In high-disease-burden countries, such as Nigeria, the adoption of the HepB-BD vaccine remains limited. Emerging global policy discussions highlight the need to examine healthcare workers' (HCWs') perceptions of pediatric vaccination guidelines, the safety and effectiveness of the HepB-BD vaccine, and how family, social support, and community factors influence vaccine delivery. Methods: A convergent mixed-methods study of HCWs was conducted in Nigeria between July and August 2024. Using the PEN-3 Cultural Model as our framework, we concurrently administered quantitative surveys and conducted in-depth qualitative interviews and focus group discussions to assess knowledge, beliefs, and peer influences related to HepB-BD vaccinations. We also explored HCWs' perceptions, enabling factors, and social influences that impact vaccine delivery. Data were analyzed using descriptive statistics and thematic analysis. Results: Most participants were women (87.8%), nurses (24.4%), and community extension workers (14.6%), with an average age of 32.5 years. Over half perceived HepB-BD vaccines as extremely safe (61%) and effective (63.4%). Participants strongly agreed that birth vaccination is recommended (80.5%), ethically appropriate (68.3%), and that its benefits outweigh side effects (63.4%). Most respondents reported professional autonomy in birth-dose decisions: 51.2% strongly disagreed that family opinions influenced their decisions, and 48.8% strongly disagreed that family/friends were concerned about their administering the vaccine. Qualitative themes included perceptions of barriers (poor knowledge, limited vaccine stock, misinformation), enablers (transportation and cold chain reliability), and nurturing factors (the role of training and collaboration with traditional birth attendants). Misconceptions included linking vaccines to sexually transmitted infections and concerns about fragile newborn immunity. Conclusion: HepB-BD vaccine delivery by HCWs is influenced by a complex interplay of multiple factors, including perceptions, structural enablers, and social relationships. As global policies continue to evolve, programs should adopt culturally responsive, context-specific strategies to address these multi-level influences and foster HCW trust, thereby ensuring the timely delivery of the HepB-BD vaccine.