Coverage and Drivers to Reaching the Last Child With Vaccination in Urban Settings: A Mixed-Methods Study in Kampala, Uganda

"Social mobilization and communication efforts should be tailored to the complexities of urban settings characterized by transient and diverse populations with different cultures."

Urban settings pose unique barriers to the delivery and utilisation of vaccination services. Challenges in the coverage and equity of vaccination persist in Kampala, Uganda, where 60% of the population resides in slum areas. This study sought to determine vaccine coverage among children aged 12-36 months living in Kampala and to understand demand-side drivers of vaccination coverage, with the goal of informing efforts to reach the last child.

Conducted in Kampala from June 2019 to May 2020, this study used a mixed-methods parallel convergent study design. In addition to a household survey administered to 4,249 households, the researchers conducted 30 key informant interviews, 7 focus group discussions (FGDs), and 6 in-depth interviews with representatives from the immunisation programme, health workers, and parents residing in areas with low vaccine coverage.

Of the 590 enrolled children, 340 (57.6%) were partially vaccinated, 244 (41.4%) had received all the recommended vaccinations, and 6 (1.0%) had never received any vaccine. Of the 244 with all recommended vaccinations, only 65 (26.6%) received their vaccines on time. Access to vaccination services was high (first dose of diphtheria, pertussis, and tetanus [DPT1] coverage of 96%), but utilisation decreased over time, as shown by a dropout rate of 17.3% from the first to third dose of DPT. Children from less economically poor households were more likely to be fully vaccinated.

Facilitators of vaccination: Of the 244 children that were completely vaccinated, almost all parents (99%) reported that understanding the role of vaccination in protecting their children from disease motivated them to ensure that their children received all the vaccines. Some parents (20.5%) reported that the fear of contracting diseases portrayed on television motivated them to ensure that their children were completely vaccinated. A few (0.8%) believed that vaccination is a child's right. In all FGDs, community members emphasised that the main reason for taking their children for vaccination was for them to acquire better immunity. Based on personal experiences, they noted that certain diseases such as polio that were common in the past are now rarely seen because of vaccination.

Barriers to vaccination: Nearly all parents with unvaccinated or partially vaccinated children (n=344, 99%) cited a lack of information on when their children should receive the subsequent vaccine as the reason they had missed some or all of the scheduled vaccinations. In an FGD with men living in the slums, respondents mentioned that health workers emphasise the need for follow-up visits but provide no explanations about the vaccines received and their benefits. Other common reasons cited for missing vaccination were vaccine stock-outs, long waiting times, hidden costs associated with vaccination, refusal by a spouse, death of a child perceived to be linked to vaccination, and media reports of fake vaccines. Some of these factors resulted in fear and mistrust of vaccines.

Figure 3 in the paper illustrates a root cause analysis on caregivers' lack of knowledge on vaccination. In the absence of adequate information on vaccination, parents are influenced by the perceptions of spouses, family, and community members, which may be inaccurate. According to the immunisation programme at the Ministry of Health, high staff turnover rates of trained/mentored health workers exacerbate inadequate information transfer, especially in private health facilities. Also, the Uganda National Expanded Program on Immunization (UNEPI) uses a uniform communication strategy in rural and urban areas that capitalises on the traditional social mobilisation structures for routine vaccination, with little consideration of the urban context. As reported here, the current mobilisation strategy overlooks the uniqueness of Kampala, including the existence of different subpopulations and the availability of a broad spectrum of media.

The findings suggest the need for continuous health education efforts about the benefits of vaccination and the importance of completing the vaccine schedule. These efforts should be tailored to the complexities of urban settings characterised by mobile and diverse populations, busy parents, and a lack of formal addresses. In addition, public-private partnerships in urban areas needs to be strengthened to address the challenges of long waiting times and informal payments for health services, which discourage patients from seeking health services.

This study's results were used to "inform the development of the urban health strategy that includes vaccination. Given the huge daytime mobile population that comes to major urban settings, innovative survey methods that capture vaccination coverage in both resident and nonresident populations need to be developed. Future research should investigate the supply-side drivers of vaccination, including the frequent vaccine stock-outs highlighted in this study."