Vaccination strategies to identify and reach zero-dose and under- immunized children in crisis-affected states in Sudan: A qualitative study

doi:10.21203/rs.3.rs-3747179/v1

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Research Article

Vaccination strategies to identify and reach zero-dose and under- immunized children in crisis-affected states in Sudan: A qualitative study

https://doi.org/10.21203/rs.3.rs-3747179/v1

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Background

In 2021, 18.2 million "zero-dose" children did not receive any DTP-containing vaccine. In 99 low-and middle-income countries, 20% of zero-dose children are conflict-affected. There is insufficient evidence on vaccination interventions to identify and reach zero-dose children in these settings. This study aimed to map and assess current vaccination strategies to identify and reach zero-dose and under-vaccinated children the crisis-affected states of South Kordofan, South Darfur and the Blue Nile in Sudan.

Methods

We conducted a cross-sectional qualitative study guided by the IRMA model framework (Identify-Reach-Monitor-Measure-Advocate), developed by Gavi. We conducted 20 individual semi-structured interviews during November and December 2022. We interviewed governmental and non-governmental vaccination stakeholders at federal, state and locality levels. We conducted a thematic analysis of interview transcripts.

Results

Zero-dose and under-immunized children in the study sites are concentrated in opposition-controlled areas, nomadic communities, and remote rural areas. Zero-dose and under-immunized children in accessible areas are identified through routine vaccination strategies and surveillance reports. Various strategies are used in inaccessible areas. This includes tasking local institutions and individuals trusted by communities to identify and reach children, and infrequent integration and co-delivery of routine vaccines with other health interventions such as COVID-19 vaccination and insecticidal net distribution. There is a lack of specific population analysis and guidance from ministries of health to measure and monitor zero-dose and under-immunized children. Advocacy is conflated with mobilization and broadly characterized as ad-hoc activities connected to immunization campaigns only

Conclusions

We conclude that there is a need for further research and testing and adapting innovative and tailored interventions in these settings, particularly in the areas of integrated vaccination delivery, community participation in vaccination, improved data generation and use and advocacy.

Zero dose children

Under-immunized

vaccination

strategies

Crisis

Conflict

Sudan.

Vaccination is a cost-effective and efficient public health measure, especially as many viral infections lack treatment and antimicrobial resistance is increasing [1]. Despite efforts to improve global vaccination coverage [2], there are still around 25 million children in 2021 who have not received the complete set of DTP-containing vaccines (three doses). Out of these, 18.2 million children did not receive any DTP doses, known as "zero dose children." [3]

The global COVID-19 pandemic has resulted in a significant increase in the number of zero-dose children in Gavi-implementing countries [4], including Sudan. A recently published report showed that 20% of zero-dose children in 99 LMICs live in conflict-affected settings [5]. Another study further highlights high rates of zero-dose children in remote rural and conflict-affected regions, particularly in parts of the Sahel and the Horn of Africa [6].

Recently, various global efforts including Immunization Agenda 2030 (IA30), Equity Reference Group for Immunization (ERG) and Zero-Dose Funding Guidelines by GAVI were established to achieve the global goal of leaving no one behind [1, 4]. The Gavi Vaccine Alliance launched the Zero-dose Immunization Program (ZIP) to address the inequity in vaccinating the most vulnerable children in 11 countries in the Sahel and the Horn of Africa regions. The program is managed by two consortia of organizations that operate in these difficult settings including, RAISE 4 Sahel (Reaching and Adapting Immunization Services Effectively to Reach Zero-Dose Children in the Sahel) and REACH (Reaching Every Child in Humanitarian) in the Horn of Africa [7].

Despite the introduction of several vaccines in Sudan, vaccine-preventable diseases have still been among the top ten causes of death for children under the age of 5 in the country in recent years [8–10]. The national coverage of the first and the third doses of pentavalent vaccine was 94% and 84% in 2022, respectively [3]. However, the Simple Spatial Survey (S3M) conducted in 2018 which has a precision at the locality level, showed that only three-quarters of children (76%) received the first dose of the pentavalent vaccine [11]. The same report underscored that Central Darfur state had the highest rate of zero dose of pentavalent (48%), while Khartoum state had the lowest (around 10%). Measles vaccination coverage was the lowest in 8 years, with 81% receiving the first dose and only 63% receiving the second dose in both 2021 and 2022 [3]. The burden of vaccine-preventable diseases is affected by the political and economic instability, as they directly affect the nutritional status of the at-risk groups, as well as the difficulty of vaccinating children in the protracted conflict areas in Darfur, South Kordofan, and the Blue Nile states [12].

After the 2018 revolution, Sudan was seeking democratic transition and economic growth. Those aspirations were dashed when the military coup of October 2021 destabilized the country's progress and governance. Furthermore, the conflict between the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF) broke out in mid-April 2023 and has escalated, resulting in over 6 million people being displaced, creating the largest population of internally displaced persons in the world [14]. The RSF's control over critical medical supplies, including vaccines, in Khartoum has further jeopardized the already fragile health services and disrupted immunization efforts [15].

To our knowledge, little is known about the strategies and practices to identify, reach, monitor and estimate zero-dose and under-immunized children in crisis-affected settings in Sudan. This study is part of a larger research project which aims to map and assess the governance and delivery of vaccines for zero-dose and under-immunized children in humanitarian settings to inform development strategies and policies to address equitable vaccination delivery in these settings [16].

Study aim

This study aimed to map and assess the existing vaccine delivery practices to identify and reach zero-dose and under-vaccinated children in crisis-affected settings across three states in Sudan.

Study setting

The research was carried out in three conflict- and crisis-affected regions of Sudan: South Kordofan, South Darfur, and the Blue Nile states. Selected for their longstanding exposure to protracted conflict situations, these areas endure persistent crises primarily fuelled by localized intercommunal conflicts often exacerbated by political motives. Such strife has escalated criminal activities and insecurity, posing severe risks to the civilian population. The governments' failure to address long-standing ethnic grievances and tensions has further aggravated the already complex situation of chronic insecurity in these states. This has led to the proliferation of armed paramilitary conflicts, undermining the authority and control of central security forces. Consequently, vast areas within these three states have fallen outside the central government's control.

Study design

This study used a cross-sectional design using a qualitative approach (in-depth interviews [IDIs]). The topic guide for the interviews was developed and structured using the IRMA framework (Identify-Reach-Monitor-Measure-Advocate) that was developed by GAVI, the vaccine alliance, to assist countries adopting a structured approach to reach zero-dose children and missed communities as a pathway to equitable Primary Health Care [4]. Data were collected from November to December 2022.

Groups and participant selection

We conducted a total of 20 in-depth interviews with three different stakeholder groups involved in the delivery of the Expanded Program on Immunization (EPI) officers/ experts at the federal, state and locality levels (Table 1). The participants were either affiliated with the governmental sector or non-governmental sector including NGOs, WHO and UNICEF. The EPI officers/experts were selected for having a leading role in the immunization program either at policy, governance or service delivery levels. From this group, data was collected through individual in-depth interviews.

Table 1

Number and type of interviews conducted
Sex	Female	6
Sex	Male	14
Nature of the institution	Governmental	12
Nature of the institution	Non-Governmental	8
State	Blue Nile	7
	South Darfur	6
	South Kordofan	5
	Khartoum/Federal	2
Total interviews		20

Interview Questions

A set of questions were asked based on the IRMA framework [4], covering four topics related to zero-dose children including identification, reaching, measurement/monitoring, and advocacy. All groups were asked questions to: understand who, where, and how many zero-dose children and communities exist and why they have been missed (Identify); identify existing strategies to sustainably reach zero-dose children and missed communities especially the supply side barriers (i.e. service availability and quality) and demand side barriers (i.e. vaccine confidence, service uptake, and utilisation) (Reach); assess whether and how data sources are triangulated to monitor identification and vaccination of ZD communities (Monitor); and explore the level of engagement of local national and local actors in support of reducing ZD children numbers (Advocacy). Direct questions on the impact of COVID-19 on vaccination services and coverage were also included.

Data collection and analysis

The individual interviews were conducted in the Arabic language by well-trained researchers in qualitative methods from the School of Health Sciences in Ahfad University for Women in Sudan. MS and AA conducted the interviews at the federal levels. The data was recorded, transcribed, manually coded, and then analysed according to the IRMA model framework by (MS) and (AA); then other co-authors reviewed the work. The data (i.e. excerpts) were matched to the categories and the sub-categories of the model framework. Afterwards, expressive quotes were selected from the transcription, translated into English, and presented in the text. Another researcher has verified the translation (NA).

The results were structured using the IRMA framework, which guided our exploration of the multifaceted issue of zero-dose and under-immunized children. This framework encompassed the strategies for identification, the reaching methods employed, the mechanisms for monitoring and measurement, as well as the advocacy efforts undertaken. Additionally, we examined the impact of the COVID-19 pandemic within this context. The data is summarized in Fig. 1.

Generally, there were underlying contextual factors identified as contributing to zero-dose children in Sudan including the political instability, the economic situation and restriction to the flow of funds from the donors especially after the after the coup d’état in October 2021, as ‘‘there were donor restrictions that the funds must not be provided to the government’’, in addition to the impact of COVID-19.

’If you looked at Sudan until 2017, we would not have had a zero-dose. I’m not talking about conflict areas or closed areas, because their reasons are clear, but I’m talking about settled areas, where the immunization services are going well. The zero-dose started to appear more after 2018 and then increased in 2022 when we reached the maximum accumulation of zero doses. There are several main reasons: political instability, the economic situation, the running cost of the vaccination increased, the fuel, the per diem, and the high turnover (i.e. staff), all these things affected the implementation of vaccination sessions. In recent years, competing campaigns began to appear, like COVID-19, which also, affected, the lockdown had an effect to some extent. Besides the flow of funds for the implementation of the session, as the majority of the staff are working as volunteers, they don’t have jobs or salaries.’’

NGO officer at the federal level

Figure 1

Existing vaccination strategies and best practices for zero dose & under-immunized children in crisis settings in Sudan.

1. Identifying zero-dose children in crisis-affected states

1.1 Zero-dose communities and their determinants in the crisis-affected states:

The participants in the three crisis-affected states identified three groups of communities with high rates of zero-dose and under-immunized children: those in opposition-controlled areas, nomadic communities, and remote rural areas across the three states.

There are many factors leading to zero-dose children in opposition areas, nomadic communities, and remote rural areas in these crisis-affected states. Firstly, some communities in or around armed opposition-controlled areas, pose a security risk for service providers attempting to reach them. Secondly, the transient lifestyle and norms of nomadic cattle-rearing communities, their intention to avoid governmental authorities to evade taxes and Zakat (i.e. Islamic alms tax), and their desire to hide their children and cattle from strangers (i.e. including immunization officers) because they fear attracting the “evil eye”. Thirdly, zero-dose communities who live in remote rural areas are partially inaccessible due to other natural factors such as the six-month long rainy season and challenging geographical terrains (i.e. mountains and creeks).

Dilling (i.e. a town in South Kordofan) has a large part of it adjacent to closed areas in Kauda (i.e. a town serving as the headquarter of rebels of the Sudan People's Liberation Movement-North (SPLM-N)). Those communities have the most zero-dose children, who did not receive any [vaccine] dose.

NGO officer at the state level

They have a belief that when someone says that he has 5 or 6 children, these children may receive the evil eye. Even in the case of cows, if you have 100 cows, you say I have 30. Some of the obstacles that we face among the target [population] are like this, which means that they believe that a person who has many children will receive evil eye, meaning that children are likely to die because there are many. That's why they hide it (i.e. the real number of children in the house). So, they never give you the real number.

Governmental officer at the locality level

1.2 Approaches to identify zero-dose children in these crisis-affected states

Identifying zero-dose and under-immunized children in easily accessible areas is performed by following the immunization micro plans at state and locality levels, which use routine vaccination coverage and vaccine-preventable surveillance reports as the main approaches.

For identification, we map out where the immunization should be done, in general, this is what we call the local micro plan. Any locality immunization office with the health promotion department develops something called a micro plan. This micro plan contains all the details of all locations and villages in the locality, and this center will provide immunization services, whether it is fixed, outreach or mobile teams, because these are the three strategies. The second thing is that they map out the catchment population in this place and then review the previous coverage.

NGO Officer at the federal level

However, there are various strategies for identifying and reaching zero-dose and under-immunized children in inaccessible areas, remote rural areas and nomadic populations, including collaboration with trusted NGOs and focal persons including the community and tribal leaders (i.e. trusted by the local government and other opposition leaders and local communities) who further cooperate and jointly work with community-based organizations and volunteers to identify these zero-dose children through coverage surveys and home visits.

We do a coverage survey to see how far the average coverage rate in the concerned area has reached. Secondly, sometimes we choose random areas to conduct a coverage survey for them. Sometimes, for example, because the coverage survey is expensive or something like that, we assign technicians to make home visits, or we find, for example, activists in a district, for example, young men, and teachers from schools, we ask them to make home visits and we give them a form to see the number of people who have not been vaccinated and who is fully vaccinated and who is not.

Governmental officer at the state level

1.3 Perceived effective strategies and best practices for identifying zero-dose children

Training of local volunteers, including young mothers, was described as the key best practice to conduct various activities of identification including community mobilization, translation from Arabic to local languages, identifying zero-dose and under-immunized children in social events in the communities, and assisting in conducting vaccination coverage surveys.

The most important factor, I see, is the training of volunteers in the community itself, which means training in the community. For example, in every village or village council, there will be volunteers who are well-trained and familiar with all information about immunization. Then, they help me. If I have an activity, I will let them engage. If I don’t have an activity, they themselves may go to a meeting (i.e. social events), such as a Naming Ceremony (i.e. a ceremony of naming a newborn), where, they may know that through chatting that someone's son is vaccinated, or last time, some were not able to catch the campaign (i.e. under-immunized), but some have never been vaccinated.

Governmental officer at the locality level

We have groups affiliated with the nutrition program, which are women's groups at the community level in all the areas where we work. One of the conditions to be part of these groups is that you are supposed to be a mother of children less than two years old. The number may vary from 12–15 per group. Each of these 15 is responsible for 10 of its neighbours, and so on. This is one of the tools with which we discover cases (i.e. identify zero-dose children)

NGO officer at the state level

2. Reaching zero-dose children in the crisis-affected states

The participants identified various strategies for delivering vaccination services to the children in these clusters. For the accessible areas, the EPI at different levels provides vaccination services using three strategies, including fixed, outreach and mobile team.

For the remote and inaccessible areas, different local strategies have been used including the collaboration with trusted NGOs and focal persons including the community and tribal leaders and ad-hoc integration and co-delivery of vaccination campaigns with other health commodities such as nutrition, COVID-19 vaccines, and insecticidal net distribution.

Thankful to God, in collaboration with the brothers in Doctors Without Borders (MSF) and CARE organizations, we were able to coordinate with them. They have mobile clinics in the east of the mountain (i.e. East of Jebel Marra, where the rebels are settled). They take their vaccines and all their supplies, and they go to the areas surrounding them to reach the children

Governmental officer at the state level

‘‘I will give you a very simple example. Two days ago (i.e. There was a national campaign to distribute mosquito nets), we were thinking about distributing mosquito nets and conducting COVID-19 vaccination at the same time. Both of them, make us very comfortable because the same person at the locality level who distributes mosquito nets is the same person in charge of COVID-19 vaccination. This would be an opportunity to raise the coverage to a percentage we do not expect. It will raise the percentage for us to a very, very high percentage, and at the same time, we ensure that the mosquito nets reach all people. If the Ministry of Health at the federal level integrated them (i.e. the two services), it would be helpful to people at the state level, because, in the end, we as states already have the idea to integrate programs together... frankly it saves time and effort’’

Governmental officer at the state level

2.1 Perceived effective strategies and best practices to reach zero-dose children

The participants described effective strategies and best practices for reaching zero-dose children in the crisis-affected states and increasing coverage of other vaccines. One of these strategies is the internal coordination with other departments inside the Ministry of Health to integrate and co-delivery of vaccination services with other services such as nutrition, COVID-19 vaccines, and mosquito net distribution. Another strategy is to collaborate with other ministries such as the ministry of animal resources in the same state or in the other states to track the movement of the nomadic communities. At the community level, ‘in advance notification’ and ‘proper coordination’ with the key persons and community leaders were identified as key to entering communities and reaching any child.

Additionally, they benefit from other vaccination campaigns that use house-to-house approaches such as polio campaigns to identify zero-dose and under-immunized children and raise awareness among parents about the importance of vaccines.

Part of this micro plan (i.e. state and locality level micro plans) is also identifying all the groups that are considered special groups, such as the nomadic Arabs. In coordination with the animal resources (i.e. Ministry of Animal Resources), they (i.e. EPI) map out their movement (i.e. nomads) ……so that they can reach them, even if they are not in their state, there is an exchange of information with the other states.

NGO officer at the federal level

Through sheikhs (i.e. community leaders), I mean, any community has a specific key person. Even for the mobile teams, when they go to a village, they don’t enter directly into that village. They need in advance notification. He (i.e. the key person) coordinates with his community and notifies them. And this is the only way, through proper coordination, you can reach any child in this area.

Governmental officer at the state level

2.2 Challenges of reaching zero-dose children

The participants described many challenges for reaching zero-dose communities including the ‘insufficient’ funds from the donors, which was affected by the political instability, and ‘donor restrictions’, especially after the coup d’état in October 2021. UN agencies tried to overcome predicted fund challenges by navigating ‘through reimbursement or direct payment modalities’. These modalities require an existing fund from the government to be processed. However, ‘the government has fund issues, and they know there is no sufficient fund for implementation’. Furthermore, immunization program-specific issues including the cold chain as ‘some centers may not have a refrigerator’, irregular vaccine delivery ‘mobile team only comes once a month, and families may be present or not on that day’, in as well as non-responsive approaches to address vaccine practical issues including the services access and acceptances ‘I do not allow a man to enter my house to vaccinate my children’.

There are many challenges, including the sustainability of the funds and the political and economic situation of the country. These caused inflation, so the funds from the donors and the partners became insufficient. Additionally, there were donor restrictions (i.e., after the coup d’état in October 2021) that the funds must not be provided to the government, and we know that the government implements immunization (80–85%) …. Even though we tried to navigate through reimbursement or direct payment modalities, the government has fund issues, and they know there is no sufficient fund for implementation….

NGO officer at the federal level

The main problem is that from the beginning of the year, we develop plans, from January through February to March; however, there is no sustainability for routine vaccination. For example, from January until the middle of the year, I could not implement all the strategies, I implemented only the fixed sites strategy. So, what about the other outreach and mobile team strategies? If the funds come after six, seven, eight months, or at the end of the year. Then, I will have an accumulation of children who were born since January.

Governmental officer at the state level

Furthermore, there was a consensus among the participants that COVID-19 disrupted routine vaccination services and undermined trust in vaccination services. Some parents avoided routine vaccinations due to fear of contracting COVID-19 and infecting their families. Some parents refused to vaccinate their children due to confusion with COVID-19 vaccination campaigns, while the lack of access to routine vaccination services led to mistrust between recipients and service providers. However, ‘with the availability of resources for COVID-19 vaccination’, these resources were leveraged the routine immunization e.g. ‘each team of COVID-19 vaccination had one member from the routine vaccination’, and also by sharing resources to be able to reach children < 1 year in challenging areas.

Additionally, there are context-specific challenges including geographic barriers and the ‘insecurity’ situation created by local tribal clashes.

''You tell them that immunization is important and people should be immunized. Then, they come and ask about the vaccine, and you tell them the vaccines are over (i.e. during COVID-19 pandemic), and tomorrow, they will come again and ask. This creates mistrust between the service provider and the person who receives the service.''

NGO officer at the state level

3. Monitoring and measuring vaccination services and coverage

The study participants appeared to lack defined strategies for the measurement and monitoring of zero-dose and under-immunized children. They described generally the monitoring and evaluation of vaccination activities as conducted either on a regular basis to collect data about vaccination or when there are ‘Any campaign, whether routine, COVID-19, or any other activity related to immunization’ to accelerate vaccination coverage. The flow of data for both activities starts from health facility and community (i.e. when there is a campaign), administrative units, locality, states and national level. Generally, data are used at different levels to address the vaccination gap.

Some participants from different levels identified many challenges regarding monitoring and measuring of routine and campaigns immunization data, including the data verification meetings were irregular and the population projections were based on a 2008 census, resulting in inaccurate calculation of target children for vaccination. Furthermore, due to the lack of capacity at the locality level, data is analyzed manually at that particular level ‘We bring the forms, calculate the dropout, and even among the dropouts, whether they missed the first or the second dose’.

Sometimes, the coverage of the penta one (i.e. the 1st dose of pentavalent) is more than 100% (110–115%), because estimating the target (i.e. targeted children for vaccination) from the beginning is challenging since the method of calculation is not accurate but we do not have another solution. It is calculated based on the 2008 census

NGO officer at the federal level

4. Advocacy

The participants in the study did not specifically delineate their advocacy efforts concerning children with zero-dose and those who are under-immunized. Instead, they conflated advocacy with mobilization, broadly characterizing advocacy as ad-hoc activities connected to immunization across federal, state, and community levels.

At the federal level, the Ministry of Health works jointly with other partners to advocate co-financing of vaccination, strengthen community mobilization and communication and conduct research to identify barriers to reaching zero-dose communities.

‘‘We always work jointly with the government, and we advocate at all levels. For, example, during the COVID-19, we conducted sessions with the under-secretary of ministries…..Generally, politicians are committed, but the challenge is transforming this commitment into real support, I mean paying and supporting the local component (i.e. co-financing), as the program is funded by donors, which puts the program at risk.''

NGO officer at the federal level

At the community level, EPI at the locality level and NGOs coordinate with community-based organizations (CBOs), community leaders or volunteers to provide logistical support including the transportation and relocation of vaccines and supplies or maintenance of refrigerators.

We consider these revolutionary committees (i.e. districts voluntary services committees were established after the revolution of December 2018 and named revolutionary committees) as keys to society. I mean, for example, if there are cases of refusal, they notify us and then explain to them, urge them to vaccinate and inform them about the vaccination schedule.

Governmental officer at the state level

There are many partners, though they are not able to provide financial support, they may help in transporting the supply. We already have volunteers or technical persons, so some partners may tell you that we can relocate your supplies to a specific area, or they may help in fixing a refrigerator

Governmental officer at the state level

To assess the current vaccine delivery practices for identifying and reaching zero-dose and under-vaccinated children in crisis-affected states in Sudan, we explored three diverse groups of participants who are affiliated with governmental and non-governmental sectors at the federal, state, and locality levels.

Our study participants confirmed the persistence of large numbers of zero-dose and under-immunized children across South Kordofan, South Darfur, and the Blue Nile states, a trend similarly observed in other conflict-affected regions globally. For instance, a study conducted in Afghanistan [15], also identified high rates of unvaccinated children in conflict zones, highlighting similar challenges in accessibility and health system weaknesses. Our findings identified three groups of communities with high rates of zero-dose and under-immunized children: those in opposition-controlled areas, nomadic communities, and remote rural areas across the three states. The United Nations Population Fund (UNFPA) estimated that up to 10% of the population in Sudan is nomadic which is characterized by little exposure to the health care systems due to their frequent movement between neighboring countries [17, 18].

Our findings also showed nomadic cattle-herding groups avoid government entities and vaccination teams due to their belief in the "evil eye" and fear of attracting negative attention. The influence of cultural beliefs and social norms on vaccination uptake was found similarly in Somalia and Kenya [19, 20].

Our research participants propose that the use of trusted NGOs (i.e. local and international), community workers and women's groups could be effective in reaching the children in need. This approach is consistent with the methods used in similar settings, especially in remote rural areas, to improve maternal and child health outcomes. However, the main challenge is to ensure that these strategies are both cost-effective and sustainable, especially in immunization services in crisis-affected settings, as demonstrated by other studies [21, 22]. Gavi has implemented two initiatives in crisis-affected settings in 11 African countries, including Sudan, using comparable approaches, such as collaborating with trusted international NGOs and local community-based organizations, to reach zero-dose and under-immunized children [7]. This could potentially be a good source of information on the effectiveness of such interventions

Our research has identified significant issues related to data quality and a lack of targeted, population-specific analysis and guidance from federal and state ministries of health concerning zero-dose and under-immunization. In addition to this, there is a notable dependence on census projections for calculating vaccination coverage, which is not reliable in crisis situations [23]. This is especially true in areas where a significant portion of the population is nomadic, comprised of internally displaced persons (IDPs) who are not accounted for, or live in remote areas that are beyond the reach of the government. Due to these gaps in data, existing immunization policies and strategies tend to be too generic and do not adequately address the specific needs of zero-dose and under-immunized children. It is important to note that this situation is not unique to Sudan but reflects challenges faced in other low-resource settings worldwide [4]. GAVI has also highlighted the critical need for robust health information systems to improve the monitoring of vaccination programs in countries with high zero-dose and under-immunized children through recommending different approaches such as Community-based Monitoring (CBM), supportive supervision and targeted surveys [24–27]. However, there is a need to adapt these approaches in crisis-affected settings.

The significance of community mobilization, as underscored in our study, is important in addressing the complex issues involved in reaching zero-dose and under-immunized children in areas impacted by crises. Nonetheless, as highlighted in our study, there is a lack of structure and guidance for carrying out advocacy across various levels. In Sudan, advocating for the zero-dose agenda requires more than just campaign-specific efforts aimed at mobilizing communities for vaccination. It is imperative to push for policy change that supports this agenda, particularly in conflict and crisis situations where it is most needed.

Our research reveals also a reported deep-seated mistrust in government authorities among the three communities studied in these crisis-affected settings, adversely affecting their use of health services, particularly preventive measures such as vaccinations. To counter this distrust, we advocate for the adoption of diverse community engagement strategies tailored to the unique needs and perceptions of these communities. To improve vaccine uptake and overall health outcomes, it is essential to not only address the immediate health concerns of communities but also build long-term trust and understanding of the importance of health services, including vaccination programs. By designing a more strategic and sustained advocacy approach for reaching zero-dose and under-immunized children that considers the specific contexts and needs of these communities, there is a potential to achieve significant progress.

Limitation

The findings of this study should be understood in the context of the participants and areas involved. Since this is a qualitative study, it's possible that there may be some unintentional biases in the selection of participants and areas. Some areas were chosen because they were easily accessible, in addition to the purposive criteria of selection. Although the interviews have provided rich details, they may not fully represent the diverse experiences of all stakeholders in other conflict-affected states. This regional specificity means that the study's wider relevance to other conflict-affected areas may be limited. Furthermore, the constantly changing political and social landscape in these regions can affect the effectiveness of the identified vaccination strategies, which are based on a fixed time frame and exclude community-level perspectives. Therefore, it's necessary to provide ongoing updates and broader inclusion for a comprehensive understanding.

Our study's results indicate that ensuring high and equitable vaccination coverage in conflict-affected areas is a complex process. Our research highlights various challenges, including cultural, logistical, and health system barriers. We conclude that there is a need for further research and testing innovative and tailored interventions in these settings, particularly in the areas of integrated vaccination delivery, community participation in vaccination, improved data generation and use and advocacy

CBM: Community-based Monitoring

CBOs: Community-Based Organizations

Children in the Sahel

DTP: Diphtheria, Tetanus and Pertussis.

EPI: Expanded Programm on Immunization

ERG: Equity Reference Group for Immunization

IDIs: In-Depth Interviews

IDPs: Internally Displaced Persons

IRMA: Identify-Reach-Monitor-Measure-Advocate

LMICs: Low- and Middle-income Countries

NGOs: Non-Governmental Organizations

RAISE 4 Sahel: Reaching and Adapting Immunization Services Effectively to Reach Zero-Dose

REACH: Reaching Every Child in Humanitarian

RSF: Rapid Support Forces

S3M Simple Spatial Survey

SAF: Sudanese Armed Forces

SPLM-N: Sudan People Liberation Movement-North

UN: United Nation

UNFPA: The United Nations Fund for Population Activities

UNICEF: United Nations International Children Emergency Fund

WHO: World Health Organization

ZD: Zero Dose

ZIP: Zero-dose Immunization Program

Ethics approval and consent to participate:

This study was implemented in compliance with the Declaration of Helsinki. Before data collection, the study was approved by the Ahfad University for Women’s Review Board (IRB), the National Health Research Ethics Committee at the Federal Ministry of Health in Sudan, and the London School of Hygiene and Tropical Medicine’s Research Ethics Committee (approval number 27465). Informed consent was obtained verbally from all study participants.

Consent for publication

Not Applicable

Availability of data and materials

The data that support the findings of this study are available on reasonable request from the corresponding author. The data are not publicly available due to ethical restrictions as they contain information that could compromise the privacy of research participants.

Competing interests

The authors declare that they have no competing interests.

Funding

This research was funded by the Bill & Melinda Gates Foundation, grant number INV-035643.

Authors' contributions

MMS, AM and NA developed the proposal. MMS and OA developed the methodology. MMS, OA and AM analyzed and interpreted the data. NA, BN, SMJ and NSS performed data validation and were major contributors to writing and editing the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We thank the researchers at Ahfad University for Women for their meticulous data collection efforts in conflict areas. Our profound gratitude is also directed towards the team at the Adeela Organization for Culture and Art for their exemplary administrative support and coordination during the tenure of this project. A special thanks to the Sydney School of Public Health for inviting the first author during the current conflict in Sudan to complete the analysis of this study.

Rodrigues CMC, Plotkin SA. Impact of Vaccines; Health, Economic and Social Perspectives. Front Microbiol. 2020 Jul 14;11:1526. doi: 10.3389/fmicb.2020.01526. PMID: 32760367; PMCID: PMC7371956.
Strategic Advisory Group of Experts on Immunization. The Global Vaccine Action Plan 2011–2020: Review and Lessons Learned.
Rachlin A, Danovaro-Holliday MC, Murphy P, Sodha SV, Wallace AS. Routine Vaccination Coverage - Worldwide, 2021. MMWR Morb Mortal Wkly Rep. 2022 Nov 4;71(44):1396-1400. doi: 10.15585/mmwr.mm7144a2. PMID: 36327156; PMCID: PMC9639437.
GAVI. Guidance on Use of Gavi Support to Reach Zero Dose Children and Missed Communities. GAVI. 2021 August. Available from: https://www.Gavi.org/our-alliance/strategy/phase-5-2021-2025/equity-goal/zero-dose-children-missed-communities
Wigley A., Lorin J., Hogan D., Utazi C.E., Hagedorn B., Dansereau E., Tatem A.J., Tejedor-Garavito N. Estimates of the Number and Distribution of Zero-Dose and under-Immunised Children across Remote-Rural, Urban, and Conflict-Affected Settings in Low and Middle-Income Countries. PLoS Glob. Public Health. 2022;2:e0001126. doi: 10.1371/journal.pgph.0001126
Utazi C.E., Pannell O., Aheto J.M.K., Wigley A., Tejedor-Garavito N., Wunderlich J., Hagedorn B., Hogan D., Tatem A.J. Assessing the Characteristics of Un- and under-Vaccinated Children in Low- and Middle-Income Countries: A Multi-Level Cross-Sectional Study. PLoS Glob. Public Health. 2022;2:e0000244. doi: 10.1371/journal.pgph.0000244.
Gavi Launches New Partnership to Reach “Zero-Dose” Children across Marginalised Communities [Internet]. Available online: https://www.Gavi.org/news/media-room/Gavi-launches-new-partnership-reach-zero-dose-children-across-marginalised (accessed on 10 Sept 2023)
Ministry of Health in Sudan: Annual Statistical Report 2017. Available from: www.sho.gov.sd
Ministry of Health in Sudan: Annual Statistical Report 2018. Available from: www.sho.gov.sd
Ministry of Health in Sudan: Annual Statistical Report 2019. Available from: www.sho.gov.sd
FMOH. Simple Spatial Survey Method (S3M II) for Sudan—2018. 2018. Available online: http://sho.gov.sd (accessed on 2 March 2022).
Musa, T.H.; Musa, H.H.; Mohammed, L.A.; Ahmed, A.A.; Kambo, R.I.; Musa, I.H.; Ahmad, T.; Kawuki, J.; Ghimire, U.; Obore, N.; et al. Epidemiology of Measles in Sudan. J. Adv. Med. Med. Res. 2019, 30, 1–9
Peacebuilding Fund (PBF) Sudan, DSWG Sudan, UNHCR, JIPS. Thematic Brief: Nomads: Shifting Livelihoods and Marginalization. JIP2021. Available from: https://reliefweb.int/report/sudan/nomads-shifting-livelihoods-and-marginalization-october-2021
OCHA. Sudan: Humanitarian Update (12 November 2023). Accessed November 15, 2023.Available from: https://www.unocha.org/publications/report/sudan/sudan-humanitarian-update-12-november-2023
Alfadul ES, Alrawa SS, Eltigani HF, Ahmed A, Siddig EE. The unraveling of Sudan’s health system: catastrophic consequences of ongoing conflict. Medicine, Conflict and Survival. 2023 Sep 7:1-5.
London School Hygiene and Tropical Medicine. RAISE. Accessed 10 Dec 2023. Available from: https://www.lshtm.ac.uk/research/centres-projects-groups/raise
Smith SS. Service delivery in Taliban-influenced areas of Afghanistan. United States Institute of Peace.; 2020 Apr 17.
El Shiekh B, van der Kwaak A. Factors influencing the utilization of maternal health care services by nomads in Sudan. Pastoralism. 2015 Nov 9;5(1):23.
Sabahelzain MM, Moukhyer M, Dubé E, Hardan A, van den Borne B, Bosma H. Towards a further understanding of measles vaccine hesitancy in Khartoum state, Sudan: A qualitative study. PloS one. 2019 Jun 20;14(6):e0213882. 24.
Kamadjeu R, Mulugeta A, Gupta D, Abshir Hirsi A, Belayneh A, Clark-Hattingh M, Adams C, Abed P, Kyeyune B, Ahmed T, Salih M, Biaou C, Toure B. Immunizing nomadic children and livestock--Experience in North East Zone of Somalia. Hum Vaccin Immunother. 2015;11(11):2637-9. doi: 10.1080/21645515.2015.1038682. Epub 2015 Sep 12. PMID: 26365693; PMCID: PMC4685689.
Ahmed AH, Mohamed G, Okeibunor J, Onuekwusi I, Mkanda P, Okiror S. Strategies to Reach Nomadic Children During Polio SIAs: Experience in Dadaab and Fafi Sub-Counties of Kenya after the 2013-2014 Polio Outbreak. J Immunol Sci. 2021 Apr 12;Spec Issue(2):1110. doi: 10.29245/2578-3009/2021/S2.1110. PMID: 33954305; PMCID: PMC8096539.
FHI 360. Leveraging the role of community health workers with community groups: Evidence on pro-equity interventions to improve immunization coverage for zero dose children and missed communities. Durham (NC): FHI 360; 2023. Available from: 1._evidence_brief_community_groups_and_chws.pdf (Gavi.org)
Checchi F, Warsame A, Treacy-Wong V, Polonsky J, van Ommeren M, Prudhon C. Public health information in crisis-affected populations: a review of methods and their use for advocacy and action. Lancet. 2017 Nov 18;390(10109):2297-2313. doi: 10.1016/S0140-6736(17)30702-X. Epub 2017 Jun 8. PMID: 28602558.
FHI 360. Leveraging Women’s Groups: Evidence on pro-equity interventions to improve immunization coverage for zero-dose children and missed communities. Durham (NC): FHI 360; 2023. Available from: 8._leveraging_womens_groups_evidence_brief.pdf (Gavi.org)
FHI 360. Use of targeted surveys to monitor immunization programming for zero-dose children and missed communities: Evidence on pro-equity interventions to improve immunization coverage for zero-dose children and missed communities. Durham (NC): FHI 360; 2023. Available from: 4._evidence_brief_targeted_surveys.pdf (Gavi.org)
FHI 360. Supportive supervision: Evidence on pro equity interventions to improve immunization coverage for zero-dose children and missed communities. Durham (NC): FHI 360; 2023. Available from: 12._supportive_supervision_evidence_brief.pdf (Gavi.org)
FHI 360. Community-based monitoring: Evidence on pro-equity interventions to improve immunization coverage for zero-dose children and missed communities. Durham (NC): FHI 360; 2023. Available from: 2._evidence_brief_community-based_monitoring.pdf (Gavi.org)

No competing interests reported.

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Vaccination strategies to identify and reach zero-dose and under- immunized children in crisis-affected states in Sudan: A qualitative study

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Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Study aim

Study setting

Study design

Groups and participant selection

Interview Questions

Data collection and analysis

Results

1. Identifying zero-dose children in crisis-affected states

1.1 Zero-dose communities and their determinants in the crisis-affected states:

1.2 Approaches to identify zero-dose children in these crisis-affected states

1.3 Perceived effective strategies and best practices for identifying zero-dose children

2. Reaching zero-dose children in the crisis-affected states

2.1 Perceived effective strategies and best practices to reach zero-dose children

2.2 Challenges of reaching zero-dose children

3. Monitoring and measuring vaccination services and coverage

Discussion

Limitation

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1