Caregiver experiences and perceptions of childhood vaccination information and messaging - a qualitative study in the urban informal settlements of Nairobi, Kenya

Abstract

Background

Despite overall progress in childhood vaccination, disparities remain across socioeconomic groups, with children from low-income communities experiencing lower coverage rates. Vaccination communication plays an important role in building trust and enhancing knowledge and awareness about the importance of vaccination. Vaccination communication strategies can shape how caregivers interpret or act on immunization messages. Previous evidence highlights gaps in vaccination messaging, especially in low-resource settings. Developing effective messaging requires careful consideration of caregiver beliefs and social dynamics. Exploring caregiver perceptions of various vaccination messaging strategies as well as the sources from which they receive this information is essential in improving childhood vaccination uptake.

Purpose

This study explored caregiver experiences and perceptions of childhood vaccination information and messaging in a low-income urban setting in Nairobi, Kenya.

Methods

Five focus group discussions (FGDs) were conducted with female and male caregivers of children under five to explore their experiences and perceptions of childhood vaccination information and messaging. A picture elicitation exercise explored caregiver perceptions of different visual communication techniques. The FGD audio recordings were transcribed verbatim in Swahili and then translated into English. An inductive coding process was used to review and summarize the transcripts into major thematic areas.

Results

Thirty-nine caregivers participated in the FGDs. Primary sources of information on vaccination included one-on-one communications with healthcare workers, mass media, mother/child booklets, and door-to-door visits by community health volunteers. These sources helped to shape caregivers’ perceptions by providing information and reminders about vaccination. Participants identified healthcare workers and community health volunteers as trusted messengers in delivering vaccine information. Most participants expressed the need for more in-depth vaccine information to assist in decision-making. Findings highlighted the need for clarity and simplicity in messaging and the role of emotional appeal in vaccination images and messaging.

Conclusion

The findings underscore the importance of tailoring childhood vaccination communication strategies to resonate with caregivers’ diverse needs and preferences. An ongoing and responsive approach to incorporating caregiver feedback in developing health messaging can ensure that communication strategies support caregiver needs. Healthcare workers and community health volunteers must also be equipped with practical communication tools and training to support caregivers in making informed vaccination decisions for their children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-24512-3.

Introduction

Immunization has contributed to a remarkable reduction in global mortality. African countries, however, still lag in childhood vaccination coverage. The World Health Organization estimates that up to 20% of African children do not receive all the recommended vaccinations [1]. This gap is driven by various factors including poverty, inequities in healthcare access, and marginalization of populations [2]. Children most likely to miss out on lifesaving vaccinations often live in underserved communities such as urban slums, conflict zones, remote rural areas, or refugee camps [2].

While the 2022 Kenya Demographic Health Survey (KDHS) reported that 80% of children had received basic vaccinations, significant disparities were observed in uptake across different socioeconomic groups [3]. Disparities across socioeconomic groups highlight the need for targeted strategies that address barriers to vaccine access and acceptance in underserved communities. Children Living in the urban informal settlements in Kenya face barriers to timely childhood vaccination, with some studies reporting delayed uptake and coverage rates falling below 50% in some informal settlements [4]. This sub-optimal coverage, combined with the overcrowded conditions typical of informal settlements, increases the risk of vaccine-preventable diseases. These conditions highlight the urgent need for targeted interventions to improve vaccine uptake.

Multiple factors related to healthcare service delivery and caregiver circumstances affect childhood vaccination uptake in Kenya. From the health system perspective, challenges such as vaccine stock-outs, healthcare worker strikes, long travel distances to vaccination sites, and inconsistent service availability create barriers to access [5, 6]. On the caregiver side, limited knowledge about vaccines, religious beliefs, and complacency can lead to delays or refusals [6]. Additionally, vaccine acceptance is shaped by individual caregiver beliefs and attitudes toward vaccines, alongside other factors such as trust in healthcare workers, cultural norms, and social influences, all of which play a role in caregivers’ decisions regarding vaccination [7].

Vaccine communication interventions are an important component of effective vaccination promotion strategies. They can educate caregivers about childhood vaccinations, remind caregivers about upcoming vaccinations, and facilitate caregiver vaccine decision-making [8]. Current approaches by the Ministry of Health in reaching caregivers with childhood vaccination information include radio, television, social media, posters, pamphlets, community events, and counseling at health facilities [9].

Gathering feedback from the community can help determine the effectiveness of communication strategies on caregivers’ knowledge, attitudes, and practices. This feedback can also provide valuable insights that can be used to tailor communication approaches and ensure messages are relevant, understandable, and culturally appropriate. Tailored communication strategies and culturally appropriate messaging can also help dispel myths and build confidence about the importance of vaccination [7]. Research in low-resource settings underscores the importance of incorporating specific individual and community perspectives into vaccination communication [10]. Such measures include exploring community-specific concerns and values to identify the localized needs of caregivers.

A study exploring the reasons for missed opportunities for vaccination in Kenya found that providing caregivers with appropriate immunization information can positively influence vaccine confidence and acceptance [11]. Previous evidence, however, points to gaps in vaccination messaging in low-resource settings. General vaccination messaging is often developed at a central level and then disseminated at the lower levels [8]. This “one-size-fits-all” approach frequently overlooks the socio-cultural and contextual factors influencing vaccination decisions at different localized levels. Although Kenya’s Ministry of Health has made strides in promoting immunization through public health vaccination messaging, gaps remain in the effectiveness of vaccination messaging. A study evaluating messages for maternal immunization uptake in Kenya found that current messaging often failed to resonate with caregivers because it was not tailored to address specific concerns, such as personal beliefs and trust in healthcare systems [12]. Similarly, another study examining the clarity and acceptability of vaccination communication in a rural county in Kenya found that only a third of participants agreed that messages they had received were clear, while a fifth perceived that the messages were culturally acceptable. The study identified the need for customized messages to meet caregivers’ diverse needs [13].

A systematic review of caregivers’ views and experiences on communication about routine childhood vaccination highlighted the need for further research in low to middle-income settings to strengthen evidence and improve vaccination communication strategies [14]. Developing effective messaging to address vaccine acceptance requires careful consideration of caregiver beliefs and social dynamics [7]. This involves examining the information sources they depend on, their interactions with the healthcare system, and the effectiveness of various strategies used in vaccination messaging. This study aimed to explore caregivers’ experiences and perceptions regarding childhood vaccination information and messaging in a low-income urban setting in Nairobi, Kenya. The study sought to explore the following questions:

1. What are caregivers’ primary sources of information about childhood vaccination?

2. Who do caregivers trust as credible messengers for childhood vaccination information?

3. What communication approaches do caregivers prefer for receiving information on childhood vaccination?

4. How do different types of vaccination messaging influence caregivers’ intentions and decisions to vaccinate their children?

Methods

Study setting

This research was conducted in the informal settlements of Nairobi, Kenya. Nairobi is Kenya’s most densely populated county, with a projected population of 4,906,355 in 2025, according to estimates by the Kenya National Bureau of Statistics [15]. More than half of Nairobi’s population resides in informal settlements. These are highly congested neighborhoods with inadequate sanitation and underdeveloped public infrastructure [16]. The inadequate living conditions, combined with the low-income status of most of the residents, contribute to persistent health inequalities in the informal settlements [4]. The urban informal settlement households are subdivided (informally) into community units as part of the Ministry of Health’s community health strategy. Each unit is assigned ten community health volunteers (CHVs), each CHV being responsible for about 100 households within the unit [16].

Study design

This study used a qualitative approach to explore caregivers’ perceptions of vaccination information. We conducted focus group discussions (FGDs) with caregivers of children under five years residing in the informal settlements of Nairobi, Kenya. The research team adopted an iterative process entailing ongoing data collection, review, and reflection.

The study objectives, which aimed to understand caregiver perceptions of vaccination communication and messaging, guided the choice of FGDs. FGDs were well-suited for this exploratory purpose, as they allowed caregivers to reflect on the vaccination messages they encountered and discuss their clarity and emotional impact. This interactive format provided in-depth insights into how caregivers receive and process different messages and enabled the research team to identify practical aspects of the messaging and areas needing improvement.

Study participants and eligibility criteria

The research sample comprised caregivers of children under five. A caregiver was defined as an adult primarily responsible for a child’s daily care and health-related decision-making. This included, but was not limited to, biological parents. The broader definition was adopted to reflect the caregiving realities in informal settlements, where children are frequently cared for informally by extended family members due to various social circumstances. CHVs helped in identifying participants who met the primary caregiving role. Key considerations included managing the child’s daily care and making decisions about their healthcare, including when to seek vaccination. Eligible participants were required to be 18 or older, residents of the purposively selected low-income settlements, and willing to participate in the study. Those who declined to consent were excluded from the study.

Sampling and recruitment

Four villages in Nairobi’s urban informal settlements were purposively selected for the FGDs (Viwandani, Kiamaiko, Mabatini, and Kaloleni). The villages were purposively selected to reflect a range of childhood immunization coverage, with two villages drawn from a sub-county reporting low coverage and two from a sub-county with higher rates. CHVs familiar with the informal settlements, supported the recruitment process. The CHVs helped identify caregivers who had varied experiences with immunization, including those who followed the schedule and others whose children had delayed or missed vaccines. This approach enabled the inclusion of a diverse group of participants, helping to capture a broad range of perspectives on vaccination communication and messaging.

Data collection procedures

Before each FGD session, participants received detailed information about the study and were requested to give written informed consent. They were informed about the voluntary nature of their involvement, the confidentiality of their responses, and the audio recording of discussions for analysis. Anonymized demographic data was obtained from the participants to help contextualize their background characteristics. Five FGD’s took place between October 3rd and December 1 st, 2022. The FGDs were carried out in Swahili, the commonly spoken language among participants. Discussions took place in local social halls within the respective informal settlements to ensure familiarity and ease of access for caregivers. These community halls were selected in consultation with CHVs. Only the participants and study personnel were allowed in the halls during the FGDs to ensure privacy and confidentiality.

Each session included seven to nine participants and lasted one and a half to two hours. The number of FGDs conducted was guided by data saturation, which was considered to have been reached when additional sessions no longer yielded new themes or insights.

A semi-structured, open-ended FGD guide encouraged participants to share in-depth responses based on their experiences. The FGD guide aimed to explore caregiver perceptions regarding the sources of vaccination information, types and preferences on vaccination communication approaches, levels of trust in various vaccination messengers, and perceptions on the appeal of different vaccination messages.

As part of the FDGs, picture elicitation exercises were conducted to explore caregiver interpretations and motivations associated with vaccination messages. Participants were presented with nine pictures, each featuring different vaccination-related messages and images, and asked to share their perceptions or interpretations of the pictures. These pictorials were drawn from vaccination communication materials from different sources and regions. They were not intended to assess current educational materials but were purposefully selected to guide and prompt discussion within the groups. The compilation included various posters and infographics conveying vaccination information in different ways, such as through factual statements, statistics, and emotional appeals. Participants in the FGD were asked to identify which images they perceived to be persuasive, informative, or appealing and those they perceived as confusing, fear-inducing, or ineffective. Following initial reflections, participants were prompted to elaborate on their selections, providing deeper insights into their thoughts and feelings about each image. This approach facilitated a rich discussion and understanding of the factors that shape how caregivers respond to various vaccination images and messages [17].

Participants were also presented with positively and negatively framed vaccination messages to understand their responses to different communication strategies. Positively framed messages emphasized the benefits of vaccination, such as protecting children from diseases, while negatively framed messages highlighted the risks of not vaccinating. Participants discussed their perceptions of each type of messaging, identifying which frame they found more persuasive and explaining their reasoning.

Separate FGDs were conducted for female and male participants. The initial focus was on female caregivers, who are typically involved in the child’s welfare in the informal settlements. Based on preliminary findings, a male FGD was added to triangulate and validate the perspectives of the female FGDs. The insights gathered from the male FGD closely aligned with those from the female groups, reinforcing that data saturation had been reached.

The FGD sessions were facilitated by a trained moderator and a note-taker with prior experience in qualitative data collection. Detailed field notes, including step-by-step documentation of study processes, were maintained to ensure transferability. Strategies to enhance credibility included creating an open and supportive environment that encouraged caregivers to share their views freely. Debriefing sessions were also conducted after each FGD to reflect on key insights and identify opportunities for improvement or further exploration in subsequent FGDs.

Data analysis

Following each FGD, audio recordings were transcribed word-for-word in Swahili, translated into English, and then back-translated into Swahili to ensure the meaning was preserved and the original intent remained intact. Personal identifiers were removed during transcription to protect participant confidentiality. We conducted an inductive thematic analysis starting with a detailed line-by-line review of each transcript to uncover key ideas and themes on childhood vaccination communication and messaging. The first and second authors independently coded the transcripts, then compared their interpretations, resolved discrepancies, and agreed on the final coding structure. In cases where consensus could not be reached, a qualitative research specialist was consulted to help reconcile differing views. Descriptive codes were subsequently assigned to individual pieces of data, enabling the exploration of ideas and categories derived from the data. Specific codes were developed for the picture elicitation activity to capture participants’ reactions and interpretations of the various visual materials presented.

Findings

Thirty-nine caregivers of children under five participated in the FGDs. Thirty-one participants were female (79.5%), while eight were male (20.5%). Most participants were between 20 and 29 years old (56%), followed by those 30–39 years old (36%). The majority of participants had secondary education (54%), while 18% had basic primary education. The majority of respondents (51%) reported having no occupation, 46% were engaged in informal business activities, while one participant (3%) reported being in formal employment. A larger proportion of the caregivers had two (41%) or three children (30%).

Table 1 summarizes the key findings from the FGDs categories, including the sources of vaccine information, preferences on vaccination messengers, preferences on vaccination communication approaches, information gaps, and the role of message framing. The codes and quotes for each category are provided in the text and the supplementary material.

Table 1.

Summary of key FGD findings

Category	Key FGD findings
Sources of vaccine information	• Information sources included television, radio, mother/child booklets, text messages, public address systems, door-to-door visits by CHVs, and healthcare workers.
Preferences on vaccination messengers	• Preference for healthcare workers and CHVs. • Mixed perceptions on the role of friends/peers, • Perceptions differed on the role of politicians and religious leaders.
Preferences on vaccination communication approaches	• Role of television and radio messaging in transmitting vaccination information and messaging. • Role of door-to-door messages in the informal settlement setup. • Mixed sentiments on the role of internet use in vaccination communication.
Vaccination information gaps	• Need for more in-depth information on vaccines, diseases prevented by vaccination, and possible side effects. • Male participants expressed marginalization in vaccination communication.
Role of message framing	• Caregiver preference for negatively framed messages as compared to positively framed messages.

Sources of childhood vaccination information

Participants identified several sources of vaccination information, including healthcare workers, door-to-door visits by community health volunteers (CHVs), mass media such as television and radio, the internet, mother/child booklets, text messages, and public address systems. The primary sources of information on routine childhood vaccinations were hospitals and CHVs. A participant describing where they obtained information on vaccination stated:

“You’ll know in the hospital, when you’ve taken the baby, you’ll be told next month there’s an injection, when they reach six weeks, that way you’ll know at the hospital.” (Female, FGD 3).

Hospitals provided information through health talks, one-on-one discussions with healthcare workers, and mother-and-child booklets provided to mothers during antenatal care visits.

Preferences on vaccine messengers

There were notable differences in messenger preferences in the informal urban setting. Key vaccine messengers included healthcare workers, CHVs, religious leaders, village elders, friends and neighbors, local administrators such as chiefs, and vaccine champions. Most participants indicated placing higher trust in healthcare workers for vaccination-related information. Several participants also expressed confidence in CHVs, considering them influential messengers for disseminating vaccination information.

“Now there are CHV’s who walk door to door, they go and tell the mother, and ask her, now this child of yours have they gotten vaccinated? How many months are they?” (Female, FGD. 3).

“You see, CHVs help a lot, and doctors too because we trust them.” (Female, FGD 2).

Similarly, a participant mentioned the importance of vaccine champions as vaccination messengers, stating:

“You find someone is paralyzed, and if you hear them give the reason, they say, my parents did not understand, if they would have understood they would have sent me to get vaccinated. Now that they were not given that vaccine, that’s why their body is like that, they can’t walk, so that’s something to let me know the vaccine is something worthwhile.” (Male, FGD 5).

There were mixed perceptions of peers’ roles as vaccination messengers. Some participants felt that they could have additional information they may have missed, while others were suspicious of their role.

“For friends, it also depends, you may not know, because I have another one who told me children are being injected, the polio vaccine had come, and I did not know ….so I can listen to them and go make sure and take the baby.”(Female FGD 3).

Most participants expressed low faith in political leaders as vaccination messengers as they perceived that politicians were only interested in personal gain and, thus, were unreliable in presenting accurate vaccine-related information. One participant stated:

“We are under them, but you know, politicians and their stuff, somebody out there is just looking to build their name.“(Female, FGD 4).

Similarly, there were mixed sentiments on the role of religious leaders as vaccination messengers, with some participants noting that they worked hand in hand with health professionals. In contrast, others perceived that their primary role was in spiritual matters. One participant stated:

“Pastor? …… (laughter)… the pastor’s job is to preach…. things about children no………When it gets to that, I will go to the hospital to ask the doctors.”(Female, FGD 1).

Messaging approach preferences

Different approaches were highlighted in the delivery of vaccination messaging. These included television advertisements, radio messages, door-to-door mobilizers, and short message texts (SMS). A participant highlighting the importance of SMS reminder texts stated:

“Even if its this small phone, messages can come in…. to remind you (about vaccination).” (Female, FGD 3).

Some participants preferred television and radio messaging, while others preferred door-to-door mobilization or town criers. A participant stated:

“I also find it helps a lot if there are people walking around announcing about vaccines. Because there is one who doesn’t have a radio, they will hear it when they (mobilizers) are moving around.” (Female, FGD 2).

There were mixed sentiments on the role of the internet in delivering vaccination messages in the informal settlements. Some perceived it as beyond reach for informal settlement residents without smartphones or who could not afford internet bundles. Some participants, however, felt that internet messaging could assist caregivers in accessing information on vaccination through applications such as Facebook.

“There are those you know on Facebook, they are those who are not. You know a lot of people are on Facebook, some people will be helped on Facebook, and some won’t be helped.” (Female, FGD 2 )

Most participants expressed the need for multiple approaches in relaying vaccination information in informal settlements to reach a wide range of individuals. A participant stated:

“Internet stuff is part and parcel of the information; you see all those that we have mentioned, we need them all to be used as a whole.” (Male, FGD 5).

Information gaps

All participants felt that the information they received on vaccination was inadequate, stating that they mainly received information on vaccination schedules or dates. They expressed the need for more in-depth information on vaccines, diseases prevented by vaccination, and possible side effects. Participants also perceived that providing adequate information would assist in their vaccination decisions. A female participant stated:

“ Mothers want to be educated a lot about vaccines, they don’t understand well what they (vaccines) help in.”(Female, FGD 3).

Male caregivers reported feeling left out and uninformed about vaccination, as they perceived that education and awareness initiatives were primarily targeted toward female caregivers, resulting in limited knowledge about immunization among men. A male participant stated:

“Then you find that men are very marginalized…. So, you find it’s often only the women’s opinion, if you hear about children, you find that even if it’s what CSO (Civil Society Organization), it first calls women, so we feel marginalized and then the information about children we have is minimal.” (Male, FGD 5).

A male participant highlighting the need for male inclusion in the provision of vaccination information and messages stated:

“Also, if you get this activity like polio (vaccination), involve men, yes so that they also know about it, even when he gets to the point where he remembers my baby should also be vaccinated.” (Male, FGD 5).

Caregivers identified the need to use multiple media and messengers, including community influencers, community health volunteers, and the local administration, to reach a vast community network.

Perception of positive and negative message framing

Participants displayed varied reactions to messages framed from a positive or a negative aspect. Most participants found negative messages on the consequences of not vaccinating a child to be attention-grabbing and compelling compared to positively framed messages on the benefits of vaccination. A participant responding to a negatively framed message stated:

“ For that one about sickness, you are going to say, I can refuse to take them, and they get polio, they don’t stand, they don’t walk, they get measles, you are scared, and you go (for vaccination).”(Female, FGD 3)

Role of vaccination messaging content and images in shaping caregiver perceptions of childhood vaccination

Table 2 summarizes the findings of the picture elicitation exercise, providing relevant quotes for each image description. The exercise revealed different caregiver perceptions of vaccination information and messaging. Key aspects that emerged included the need for clarity and simplicity in messaging and the role of emotional appeal in the images and messaging used in vaccine communication.

Table 2.

Picture elicitation exercise findings

Image No	Description*	Key finding	Sample Quotes
1	A poster displaying factual messages on eight reasons for vaccinating a child.	Most participants perceived that they needed more explanation to understand the poster.	“You know there are different people, everybody understands it differently.” (Female, FGD 2)
2	A picture featuring children disabled by polio and walking with the aid of crutches and text emphasizing that children who do not receive vaccination are at greater risk of acquiring life-threatening diseases.	Most participants perceived the poster as saddening and communicating the need for vaccination to the mother.	“There’s this one, those children missed vaccinations until they walked with sticks (crutches), because they missed vaccinations. It tells us that unvaccinated children are at risk of disease.” (Female, FGD 3)
3	A picture featuring a dull-looking child suffering from measles and presenting with a typical maculopapular facial rash. The text in the picture emphasizes that a child who does not receive vaccination is at a greater risk of acquiring life-threatening diseases.	Most participants perceived the poster to portray a very sickly child. Some participants felt that it helped portray the need for vaccination. However, a few participants said they would not want the image used in vaccination messaging.	“The information is clear, but the picture is not appealing.” (Female, FGD 1) “The child is in a bad state. The picture makes me feel very bad; I wouldn’t want it to be used in my vaccination book.” (Female, FGD 3)
4	A picture featuring a smiling man carrying a calm sleeping child with text emphasizing that vaccines protect the child, and the words love, trust, protect.	Most participants found the picture appealing, and some also stated that it positively portrayed the role of male involvement in vaccination.	“It is a good photo showing male involvement, and this is a good thing.” (Female, FGD 4)
5	A picture showing a child grimacing while receiving an injection with the message “Ensure your child has been vaccinated.”	Most participants stated that the picture was perceived to be scary and unappealing.	“It scares me because the child is feeling pain.” (Female, FGD 2)
6	An infographic providing various facts about vaccines, e.g., vaccines are safe, they are studied effectively before and after they are released, and widespread vaccination helps protect communities from outbreaks.	Some participants perceived the poster to present factual information, but some perceived the information to be excessive.	“Yes, it has a lot of things, there are those who can accept it and there are those who can reject it.” (Female, FGD 2)
7	An infographic giving vaccination information using numbers, e.g., - Vaccines save 2–3 million children from diseases. - Only 45% of children under five globally are reached with lifesaving vaccines.	Some participants perceived that the infographic demonstrated the usefulness of vaccination in saving lives and preventing deaths. However, some participants felt that the numbers presented some confusion in interpretation.	“So many children are unreached by vaccination leading to deaths. It strongly convinces the mother to take the child for vaccination.” (Female, FGD 1) “If you have given it to someone who does not know how to read well, it will have to be explained slowly…. to understand it.” (Female, FGD 2)
8	A picture of a smiling woman holding a sleeping infant with the message that vaccines protect the child and the words love, trust, protect.	Most participants stated that the picture was appealing and positively portrayed the mother’s love and protection of her child through vaccination.	“It shows the mother has placed the baby on her chest, loves the baby and loves her life.” (Female, FGD 2) “It’s pleasant, it shows that vaccines help protect the child.” (Female, FGD 3)
9	A picture featuring images of a smiling man, child, and woman with the message “Immunize your child, love them, protect them, take them for vaccination.”	Participants perceived that the poster was appealing and conveyed the importance of vaccination.	“I feel good if I take a child to the clinic, even the husband is happy.” (Female, FGD 2)
*Due to copyright considerations, only the description of the images used in the exercise is provided, rather than the actual images.

The appeal of vaccination communication materials emerged as a key theme in shaping participants’ vaccination decisions. Positive reactions were particularly noted for posters depicting male support, with participants appreciating how these visuals highlighted male involvement in childcare. One such picture, showing a smiling man carrying a calm, sleeping child, with messaging that vaccines protect the child, was seen as visually appealing and a positive representation of male participation. Similarly, a similar picture of a smiling mother holding a sleeping infant with the message that vaccines protect the child was perceived as emphasizing the mother’s vital role in protecting her child through vaccination.

In contrast, a picture showing a child grimacing from an injection was seen as frightening and unappealing, demonstrating the negative impact of distressing images on perceptions of vaccination. Additionally, while some participants perceived that a picture portraying a very sickly child highlighted the importance and urgency of vaccination, others felt it evoked sadness and were uncomfortable with such a portrayal, expressing concerns about using similar visuals in vaccination communication.

Many participants felt that pictures only displaying detailed factual information needed more explanation to be fully understood, emphasizing the importance of clear and simple messaging. Similarly, participants had mixed reactions to a statistics-based poster. While a few participants perceived it as informative and helpful, others found the numerical content overwhelming or confusing.

Discussion

Understanding what resonates with caregivers can assist in creating messaging that not only informs but also engages them more deeply to aid in childhood vaccination decision-making. This paper explored caregivers’ perceptions and preferences on vaccination information and messaging. Consistent with previous evidence [18, 19], caregivers’ vaccination intentions were influenced by their perception of the risks posed by vaccine-preventable diseases and the protective benefits of vaccines. Similar to previous research [20, 21], the FGDs identified healthcare workers and CHVs as influential in supporting caregiver vaccination decision-making processes. Evidence shows that healthcare workers can provide crucial support to simplify caregiver vaccination choices for their children [14].

Findings also showed the role of vaccination communication in caregiver vaccination decisions. Caregivers were motivated by messaging that highlighted emotions such as parental love and hope for their child’s future. Negative emotional messaging that included anticipated regret or guilt from not vaccinating was also a persuasive factor in vaccination messages. A study investigating how persuasive communication affects routine vaccination uptake in Kenya showed that message content positively influenced the adoption of routine immunization [13]. Additionally, communication that utilizes emotional appeals has been shown to facilitate the intuitive and impulsive dimensions of caregiver decision-making processes on immunization [22]. Further examination of such approaches is needed to guide vaccination communication strategies.

Given the differing needs of caregivers, the study findings highlight some strategies for promoting vaccination among caregivers. Lessons learned for developing vaccination messaging content include considering the message content and the messenger. The messenger’s credibility is key to how a message is received and accepted [23]. Even when two different messengers deliver the same information, their perceived credibility can lead to varying interpretations and outcomes [24]. As caregivers’ trust in various vaccine messengers is contextual, communication strategies should be based on feedback from specific audience preferences and empirical evidence. Since distinct groups may react differently to various messaging strategies, persisting with a uniform vaccination communication approach can overlook caregiver needs, especially in marginalized populations.

The study identified specific factors in messenger preferences and communication channels that are particularly relevant in informal urban contexts. Populations in urban informal settlements often come from diverse ethnic and cultural backgrounds with less cohesive social structures than those typically found in other settings such as rural areas. Previous evidence also shows significant disparities in the coverage and timeliness of vaccination among various ethnic groups in the informal settlements in Nairobi [25]. Such diversity necessitates careful selection of trusted messengers, as perceptions of credibility may vary widely with the different experiences and social dynamics that influence who people trust for health information. Unlike more homogenous rural communities, where traditional figures such as chiefs, village elders, or religious leaders often serve as effective messengers, informal settlements may require a broader range of influencers, including CHVs and peer influencers, to effectively reach diverse populations.

Additionally, although digital and social media platforms are recognized as practical tools for health messaging in urban settings, their reach in informal settlements may be limited by uneven access to smartphones and internet connectivity. Previous evidence shows that even among the youth, access tends to be associated with higher levels of education, which may exclude those from lower socioeconomic backgrounds [26]. Communication strategies should, therefore, incorporate a mix of approaches that are both accessible and acceptable across different socioeconomic groups.

Findings show that a multifaceted approach to vaccination communication is needed to meet the diverse needs of caregivers in urban informal settlements. Similarly, a study in Ethiopia found that caregivers favored different methods, including face-to-face and interpersonal communication, mass media, and traditional approaches such as community conversations [5].

While the current communication approaches, such as the use of mass media, are valuable, the findings suggest that they may not sufficiently address caregivers’ informational needs. Caregivers wanted more in-depth information about vaccines, specifically, the diseases they prevent and potential side effects. There is a need to review and refine the content of current vaccination communication to support informed decision-making.

The findings also show that male caregivers are less frequently reached by existing communication approaches. Immunization programs need to incorporate a gender lens in vaccination communication. More male-inclusive strategies are needed to address this gap. Such approaches can include leveraging peer-led sensitizations by respected male champions [27]. Additionally, targeted messaging delivered through community forums or male-oriented platforms could enhance reach [27].

Findings on the perceived information gaps by caregivers also show that more evidence is needed on healthcare workers’ training needs on vaccination communication, especially for marginalized groups. Previous studies have shown gaps in healthcare workers’ capacity, particularly in their communication skills [28, 29]. Healthcare workers and CHVs must have the necessary tools and skills to deliver consistent and clear vaccination messages to meet caregiver information needs and support their vaccination decisions. Recommended measures include comprehensive and hands-on training to strengthen the communication and counseling skills of CHVs and healthcare workers, including motivational interviewing skills [28]. This would help build their confidence in communicating about vaccines. Other measures include the provision of appropriate job aids, such as pictorial vaccination counseling cards and flip charts, to enhance message delivery. Additionally, the use of messaging toolkits can assist in ensuring that the provided messaging is tailored according to the caregivers’ needs, background, and barriers to vaccination [30].

The study findings demonstrate the utility of participatory techniques, such as picture elicitation exercises, in supporting comprehensive insights from FGDs in low-resource environments [17]. These methods have been found to improve participant engagement, resulting in improved data quality through enhanced participant interaction [31]. The picture elicitation exercises assisted in gaining insights into participants’ perceptions of different vaccination messaging, including which approaches were more engaging from the target audience’s perspective. The exercise underscored the important influence of vaccine messages in shaping subjective norms. Caregivers’ perceptions of what others, such as family members, peers, or community leaders, believe about vaccination can influence their decisions. For example, images portraying the involvement of family members or peers in the vaccination process may reinforce positive social norms, encouraging caregivers to align their behaviors with these perceived expectations. By highlighting the support for vaccination by peers or family, such messages can contribute to a sense of shared responsibility, further motivating caregivers to vaccinate their children. The caregivers’ positive perception of male involvement also underscored the importance of inclusive messaging in vaccination information and messaging approaches.

The mixed perceptions of factual and statistical messages highlight the need for clear, straightforward communication tailored to the target audience and carefully considering how the information is presented. Caregivers’ views on the messaging also emphasized the importance of balancing simplicity and emotional engagement. While emotionally engaging approaches are important, excessive negativity or fear-inducing images could alienate some audiences.

The study’s limitations include its focus on an urban informal settlement, which may limit its generalizability to non-urban or more affluent populations. However, the study provides valuable insights and evidence for broader applications. Another possible limitation was the risk of bias in recruiting FGD participants using CHVs. Though the criteria for participant selection were clearly communicated to the CHVs, some bias may have still influenced the purposive selection process. Additionally, the analysis focused on shared themes, with focus groups serving as the unit of analysis. While this limited presentation of individual contributions, we ensured diverse perspectives were fairly represented both in the discussions and in the analysis.

Conclusion

In conclusion, the findings underscore the importance of tailoring childhood vaccination communication strategies to resonate with caregivers’ diverse needs and preferences. An ongoing and responsive approach of incorporating caregiver feedback in developing health messaging and vaccine information can assist in ensuring that communication strategies support caregiver needs. As trusted messengers in delivering vaccination information, healthcare workers and CHVs must be equipped with practical communication tools and training to support caregivers in making informed vaccination decisions for their children. Immunization programs should adopt a multidimensional vaccine communication approach that includes face-to-face engagement, use of mass media, and community-based initiatives. Immunization programs must also integrate a gender-sensitive perspective that ensures inclusivity by targeting female and male caregivers to improve childhood immunization rates.

Abbreviations

CHV

Community health volunteer

FGD

Focus group discussion

KDHS

Kenya Demographic Health Survey

Authors’ contributions

JG: Conceptualization, Investigation, Methodology, Formal analysis, Writing -original draft, Writing- review & editing; BN: Conceptualization, Formal analysis, Methodology, Supervision, Writing- review & editing; FW: Conceptualization, Supervision, Writing- review & editing.

Funding

This research received no specific grant from any public, commercial, or not-for-profit sector funding agency.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

All procedures involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical clearance was obtained from the Strathmore University Institutional Ethics Review Committee, registration number SU-IERC 1364/22. A research permit was also obtained from the National Commission for Science, Technology, and Innovation – license number NACOSTI/P/22/19158. All participants provided informed written consent prior to their participation in the study. The consent process followed ethical guidelines, emphasizing voluntary participation, the right to withdraw at any time, and the confidentiality of participants’ data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.