Baseline Vaccination Coverage Survey
The vaccination coverage of the target slums is featured in Figure 1, along with antigen-wise coverage in Figure 2, showing the highest rates for BCG and OPV0 and the lowest coverage for Measles 2.
Figure 1. Immunization coverage among children aged 12-23 months in the study areas (n=840)
Figure 2. Immunization coverage by antigen in percentage among children aged 12-23 months in the study areas (n=840)
The survey also revealed that only 51% of respondents who received any vaccine dose reported retention of the EPI card. Additionally, scars from the BCG vaccine were reported as present in 72% of cases. Moreover, as shown in Figure 3, a greater utilization of outreach services by families was seen for doses later in the vaccination schedule.
Figure 3. Immunization service utilization in percentage at different points in the vaccination schedule (n=840)
Demand-side barriers to immunization
1. Household barriers: Permission for immunization was frequently withheld by the main decision-maker (in most cases, the child’s father or a family elder). Additionally, women had restricted mobility, many only permitted to leave their homes with a companion. Several respondents complained that household duties preventing them from seeking immunization services, and that family member were not supportive.
According to the father of a partially vaccinated child, “If a husband does not permit the child to get vaccinated, the wife will not go. In this area, none of the husbands approve of vaccination…only when a child gets ill then she has permission to take the child to the hospital, but with another woman.”
2. Lack of knowledge and awareness: Many caregivers had little knowledge about vaccine-preventable diseases and were not aware of the benefits of immunization or the consequences of forgoing it.
A mother of an unvaccinated child remarked: “I didn’t do anything to protect my daughter against measles as I thought that she should get them, as people say that it is better for children to have measles early on…the symptoms are not as serious in kids as they are in adults.”
3. Myths, misconceptions and fears: Common beliefs that immunization caused sterility, early puberty, illnesses, fever and disabilities discouraged caregivers. Some respondents also believed that providers used expired or impure vaccines, while several others perceived initial vaccine doses to be adequate for protection against all diseases.
According to a father of an unvaccinated child, “We get scared because these vaccines are imported…it’s obvious that as the vaccines are imported from other countries, they definitely want to halt our generations. These vaccines also cause boys and girls to reach puberty quickly and decrease men’s ability to reproduce.”
4. Social and religious barriers: Stigma from relatives and the community prevented many caregivers from accepting immunization. Several respondents also believed that immunization was religiously forbidden. Many mentioned that religious or social influencers had prohibited immunization.
According to a popular spiritual healer of the community, “Our supreme protector is God…I have also gotten sick but I never took any medicine, I only drink water that has been blessed with the name of God…if you stay in a state of ablution you’ll stay protected…there is no need for routine immunization for protection.”
Supply-side implementation barriers to immunization
1. Underperformance and negligence of immunization center staff
Reports of forceful or dismissive behaviour of staff members towards caregivers were plentiful. A lack of commitment to tasks was also reported to be stemming from confusion about the division of roles and responsibilities. A lack of monitoring mechanisms and accountability was also described. Frontline staff such as vaccinators were reported to underperform in terms of limited outreach engagement and frequent absences. Staff members also mentioned receiving inadequate training on community mobilization and counseling.
According to a LHW, “Someone should be present at the center daily…the vaccinator is not present there, he would only come for two days out of the week and would be absent for the rest. Parents get confused…they don’t want to come back again, after observing the condition of our center.”
2. Inefficient allocation and utilization of funds
There were several complaints regarding limited funds for outreach activities, such as inadequate provision of motorcycles and petroleum, oil and lubricants (POL) for vaccinators. Additionally, there were no performance-based incentives and lack of direct salary payments for frontline staff, with complaints of funds being withheld by senior management. Further, vaccination centers were said to have subpar infrastructure and maintenance.
According to a Vaccination Supervisor, “When all the work is done by the vaccinators but the funds are going to one person (Town Health Officer), problems arise…we can make people work only when we facilitate them and provide money, but that’s not the system here.”
3. Unreliable and underutilized immunization coverage and household data
Data collected by frontline staff and record-keeping by LHWs was criticized for incompleteness, whereby unimmunized children are not documented using personal identifiers and hence cannot be approached during outreach activities. Additionally, the lack of a birth registry and community line-listing to facilitate vaccinators and support outreach activities was discerned, as well as the absence of an electronic system to track coverage.
According to a Senior EPI Supervisor, “If we talk about data then the national programs we have, like LHW program, are not authentic…according to the list, there were five children in a house but when I visited I found just one child there, so the data they took is either incorrect or reshuffling occurred.”
4. Interference of polio campaigns with routine immunization
There were several claims that an exclusive emphasis on polio vaccination by frontline staff was leading caregivers to choose it over adherence to routine immunization. Additionally, exhaustion of resources and staff due to polio campaigns was reported. Some respondents shared that when doctors who draw caregivers to immunization centers are redirected to polio campaigns, caregivers stop visiting the centers to get their children vaccinated.
According to an NGO vaccinator, “LHWs…their main focus is polio…LHWs take us to the houses and if we encounter a family that refuses vaccinations, they (LHWs) say ‘leave them…don’t even counsel them, don’t pressurize them.’ Instead of helping us, they side with the mothers, saying ‘…because of you they’ll even refuse the polio vaccine as their kids will run a fever due to the vaccination you give them.”
Phase 2 Analysis: The Six-Step Validated Implementation Framework for Immunization in Peri-Urban Slums
Phase 2 analysis lead to the development of an immunization implementation framework for peri-urban slums. The policy recommendations contained in the framework to address the aforementioned barriers include: 1) a structured HR department for improved immunization staff management, 2) staff training on counseling, and social and behavior change communication (SBCC), 3) re-allocation of funds towards staff incentives, POL and vehicles for outreach activities, direct salary payment of frontline staff and center infrastructure, 4) a digital platform for frontline staff integrating birth registry and vaccination tracking systems as a real-time monitoring and reporting mechanism, 5) use of the digital platform for setting accurate immunization targets as well as for generating dose reminders, and 6) mutual sharing of resources, workers and data between the EPI, LHW and polio programs for cost-effectiveness and improved immunization coverage. The recommendations are detailed in Figure 4.
Figure 4.The 6-Step Validated Implementation Framework for Routine Immunization