The results are presented in four thematic areas: ‘Barriers to utilisation of vaccination services’, ‘Enablers to utilisation of vaccine services’, ‘Recommendations to improve use’, and ‘The role of mobile technology to improve health and vaccine coverage’. Under each theme, anonymous quotations are presented to illustrate the main points that emerged in the discussions.
From the users’ and health providers’ perspectives, the barriers to access and utilisation of vaccination services, as reported by service users, community leaders and service providers, are many. They are categorized into user’s (demand-side), structural and supply-side barriers. Regarding perspectives on key inherent barriers to utilization of vaccination services, six (6) themes were identified: Opportunity cost of seeking vaccines versus making a living, Distance/Cost to health facility, Availability of service provider, Attitudes towards and decision making regarding the benefits of vaccines, Awareness of the importance of using vaccination services and knowledge of availability of service, and Attitude of service provider. To elaborate on the findings, anonymous quotations bearing the participant’s number according to the order and type of interviews are presented.
i. Opportunity cost of seeking vaccines versus making a living
Some women reported that in the absence of their spouses and financial support, they have to make a living. As such, it is hard to prioritise visiting a health facility for vaccines when they have to work.
‘‘I know that vaccines are important but it is important to get food for my children too…. I cannot leave my garden to go for a vaccine, when my child is not sick. How will I feed my children? The landlord will not understand that I have no rent’’ (R6, Women FGD, Busi Island)
Furthermore, because services are not entirely free, one has to first get the money before going to a health facility.
“We are told that government facilities are free including in the national referral but when you go there that is not the case. You have to part with some money to be assisted. You pay before being assisted!” (R1, Women FGD, Busi Island).
ii. Distance/Cost to health facility
Distance and cost to get to the health facility is prohibitive as a standalone but also intersects with household power dynamics in decision making and spousal control of income to act as barriers to vaccination. This is clearly stated below.
“Most men (spouses) don’t want to provide money to go for immunization. That limits me in terms of transport.” (R8, Women, FGD, Zzinga Island).
“Transport (to the islands) is a challenge and the Health Centres are very basic in facilities. The Health Centre of Ggoli is far off and it costs 30,000 = ugx to and fro, and yet they have all the facilities” (R5, Women FGD, Zzinga Island).
“We use a lot of money to come for health care. Sometimes you have to come and spend the night on the island where the vaccines are. You have to spend money on accommodation and transport. That is a serious impediment to access” (R2, Women FGD, Busi Island).
‘If I have transport challenge I can’t come. They made an outreach once for 3 months and stopped’ (R1, Women FGD, Zzinga Island)
iii. Availability of service provider
The presence of the health service provider at village and facility level is a barrier to access. This is compounded by the lack of drugs when health workers are present as well as deployment of health workers who have families to return to outside the islands. This is evidenced below.
“VHTs are the most available but the Health Centre workers are far’’ (R8, Women FGD, Zzinga Island).
“You are sometimes worried about the absence of the health workers at the HCs even on the days they have claimed they are to vaccinate” (R2, Women FGD, Busi Island).
“All is well with accessing vaccines but the problem is with child birth or delivery…all the midwives are not from within the islands and that presents a challenge (R6, Women FGD, Zzinga Island).
iv. Attitudes towards the vaccines
Attitudes of mothers toward vaccines play a role as barriers. Some are worried of the side-effects and this weaves into their interaction with older women that didn’t immunise their own. Myths and misconceptions have a role to play as barriers.
“The injections given to the children are painful and you spend sleepless nights. Even the older people who weren’t vaccinated are opposed to the practice and they claim it causes cancer” (R3, Women FGD, Busi Island).
“Some still have myths and misconceptions” (Health Coordinator1, KII Wakiso).
v. Decision making regarding the use of vaccines
Women’s lack of control over decisions to get their children vaccinated or not are eminent in this setting. In many cases, men have the final say in the decision making process for seeking health in general and for vaccines, in particular.
‘My husband said that I cannot get his children immunised. So my children are not immunised’. (R4, Women FGD, Zzinga Island).
vi. Knowledge of availability of services
The level of awareness varies and in some instances knowledge of availability of service exists but is deterred by negative attitudes towards the service.
“I for one do all the immunisations for my children. But some people don’t because they hold old notions that others can live without immunisations. What they don’t know is that there are some new diseases that have emerged and even the nature of food we eat is poisonous” (R1, Women FGD, Busabala).
“…the major barriers are cultural beliefs, distance and finances” (Health provider 1, KII Zzinga Island).
vii. Attitudes of service providers
The attitude of health workers is imperative in vaccination uptake. There is concern over priority for immunisation by mothers that go with partners while others are pushed behind the waiting lines. This discourages mothers that don’t have partners present. This is not the case in private facilities where users pay and are attended to without regard to status.
“In government they prefer women who go for ANC and Immunisation with their partners/spouses and yet some of us don’t have them…those with them then jump the queue. Even the time for lunch is lockdown by the health workers and we have to wait.” (R4, Women FGD, Busabala).
“In the private facility you pay for the service and you are well worked upon but in the public facility, they want you to pay a bribe for service delivery. They sometimes harass you when you delay to go for ANC”. (R2, Women FGD, Busabala).
For some mothers that understand the importance of vaccination, how they are received and handled by health workers at the facility becomes an enabler or deterrence. This includes counselling by health workers besides treatment.
“When you go for ANC you are well handled in the HC II. I was counselled on not worrying due to the blood pressure level being sporadic and affecting the unborn baby (R9, Women, FGD, Busi islands).
2. Enablers of vaccination service use
The users demonstrate to various enablers on their own side as well as those from the health structure. On the user’s part, these include motivation due to the health benefits as well as concern for the long term risks associated with non-vaccination of the their children. On the health system’s part, these include the resources (presence of health workers, vaccines) as well as the way health workers handle the mothers. Specifically, the enablers include: specific dates and time allocated to vaccinations; getting consultation about the status of both baby and mother; presence of VHTs as mobilizers and immediate health support staff; handling of clients by health workers; health seeking behaviour of mothers and concern for their offspring; and the presence of medical stocks for immunisation.
The study established that having specific dates and time allocated for vaccinations is crucial in addressing maternal and childhood health in fishing communities. This is amplified by a woman below:
“When it comes to vaccination, we are given specific days and times and if you are in time, you are attended to. The problem comes when you are out of time and day…you are not attended to’’ (R3, Women FGD, Busi Island).
Specifically, the presence of VHTs is a big enabler in islands, some of which do not have any health centres due to population size. This can be illustrated below:
“VHTs have been effective on our health care and 5 years ago it was bad but the presence of health centres and VHTs has improved on the our wellbeing. VHTs train us in nutrition too” (R2, Women, FGD, Zzinga Island).
Their impact is less felt on the landing sites of the mainland but it is influential in mobilizing the population for vaccinations.
3. Recommendations to improve
Recommendations to improve on utilisations of vaccination services are two-fold, and these include access and experiences with health providers. On the part of the access, there should be ease of access to by clients to both the health centres/workers as well as to vaccines. There are also concerns for the welfare of the health workers as well as conduct of health workers towards clients. These recommendations are various and among others include:
i. Outreaches to bring vaccines closer to island communities that don’t have health centres. This would mitigate cost, distance and time constraints. This could include allocating specific immunisation days per village. This is elaborated below:
“VHTs should be enhanced to improve on vaccination and family planning services. There should be ease of access and outreaches per village (R8, Women, FGD, Zzinga Island).
The above is in agreement with the residents of Busabala landing site on the mainland:
“VHTs should organise mobile immunisations from house to house or at the village centre” (R3, Women, FGD, Busabala).
ii. Increasing on the time for vaccination beyond midday
The requirement that vaccinations are not done beyond midday affects several women who have to cross between islands to access vaccines. They suggest that time for vaccinations should be increased beyond midday to cater for such structural impediments.
“…for us who have to move beyond our local island to the island where vaccination is…the end time of midday should be extended” (R7, Women FGD, Busi Island).
iii. Skilling the VHTs more to handle vaccines better
The VHTs have basic health training to manage vaccination and primary health diseases. This, the users feel is not sufficient given that in most islands they are the frontline and end line workers.
“They need to be given refresher courses on how to handle illnesses” (R2, Women FGD, Zzinga Island).
iv. Motorised ambulance for complicated and referred cases to the mainland
Most users indicate that there was a free motorised boat ambulance but it broke down and was not sustainable. This used to ensure access to maternal and child care services for emergency cases. This should be revived to ensure uptake of health services.
“Sometimes transport is hard due to hard-to-reach-nature of my village. We have to mobilise transport and get a motorised boat and they are sent to Entebbe for further management” (R4, VHT FGD, Ggaba).
v. Mothers without vaccination charts need to redo the exercise regardless
Many mothers claim to be at different stages of the immunisation process yet present no evidence in terms of vaccination charts. This, VHTs suggest, should be overcome by them redoing the vaccination process.
“…it becomes difficult to determine the evidence of vaccination so we usually suggest that such mothers and children redo the vaccination in its entirety” (R7, VHT FGD, Ggaba).
vi. Better remuneration and working conditions for health workers
“I suggest that the District HO to support the VHTs financially with emoluments for them not to sell the drugs” (R6, Women FGD, Busi Island).
vii. There must be enforcement of the Immunisation Act
Most mothers are unaware of the Immunisation Act of the republic of Uganda, 2017 that makes vaccination mandatory.
“Mothers who don’t vaccinate are uninformed about the Immunisation Act 2017 that makes immunisation mandatory” (R7, VHT FGD, Ggaba).
viii. There should be better handling of clients by health workers
Users appreciate the work of VHT and health workers and the circumstances in which they operate but request for better interpersonal relations with them. Short of this, the users feel unappreciated by health workers.
“The VHTs are good and from our own community, but when we approach them they are sometimes diffident. Even the Health workers are lax at times. They don’t attend to us in detail. I once spent 5 hours without being attended to. But the medication of the VHTs is effective” (R4, Women FGD, Busi Island).
4. Role of mobile technology for health and vaccine coverage
The role of mobile technology for health and vaccine coverage is an end outcome of this project. Various projects have used mobile technology in health service delivery but this project is the first of the kind to focus on vaccination. There was need to assess whether such technology could aid health service delivery. The roles are mainly: contact with health workers during antenatal and child care; and the mobile application being faster and able to auto-detect errors, something that take longer when using a register. There are several anticipated roles of mobile technology in health as indicated below:
“A mobile phone is good. We have a health worker who comes from Wakiso district and is not a resident of the area. But we inquire from him as to his availability and he tells us when to get him” (R9, Women FGD, Zzinga Island).
“Sometimes when our children are sick in the night we call VHTs via mobile phone to get immediate first aid” (R2, Women FGD, Zzinga Island).
“The register is so time-consuming due to variables involved. With an application, the systems auto-detects mistakes and they are corrected rather than wait for the supervisor” (R9, VHT FGD, Busabala).
“This is a great innovation. However there are two strands: those who can use the mobile applications and those that are not versatile due to age and may not use it. There are those you train and they may not accept them. You also need to be careful of network availability; power for charging the battery…there is a proposal to take electric power to Busi Island but not Zzinga, which is further and yet smaller” (Health coordinator 2,KII, Wakiso).