The Last Stretch: Barriers to and Facilitators of Full Immunization among Children in Nepal's Makwanpur District, Results from a Qualitative Study

"...mutual trust as a key pathway toward reaching full immunization coverage in Nepal..."

Nepal has a long way to go to achieve its goal of 95% immunisation coverage by 2030. This study presents findings from the formative assessment of the Rejoice Architecture Project, a social-norms-based intervention aiming to improve child vaccination in Nepal. To do so, the project addresses demand- and supply-side barriers to and facilitators of immunisation in Makwanpur District, Nepal, where the percentage of children fully immunised as per the National Immunization Programme (NIP) schedule was 68% in 2020.

By speaking with 76 participants, the researchers assessed: knowledge, attitudes, and experiences with immunisation; social norms related to immunisation; perceptions of local health facilities; and descriptions of client-provider relationships. Specifically, they conducted: 10 in-depth interviews with 5 fathers and 5 grandmothers of children under the age of 2; 12 key informant interviews with 4 female community health volunteers (FCHVs), 4 health workers, and 4 local government representatives; and 8 focus groups with 54 mothers with children under the age of 2 (for 2 of the 8 focus groups, only individuals from marginalised castes were sampled to gain a more comprehensive sense of the community's wide array of experiences). Data were analysed using an iterative, grounded theory approach.

Major findings include:

• Demand side:
  • Facilitators: High demand for vaccines among mothers of young children appeared to be facilitated by several factors, including a generational shift in attitudes toward immunisation, notable awareness and knowledge of immunisations, and positive social norms. Some caregivers attributed their knowledge to the receipt of education. Mothers also identified other sources of information, most commonly FCHVs. Mothers also frequently reported learning about immunisation through social networks; in fact, several mothers served as vaccination ambassadors, sharing information about vaccines with their peers and educating the community.
  • Barriers: There are lingering misconceptions and negative attitudes toward immunisation in the community and among family members. Most of the comments made about negative attitudes from older generations were perceptions of others' (not participants' own) parents, grandparents, and in-laws. Therefore, this theme may reflect the projection of community norms rather than personal beliefs. In addition, some caregivers reported they bring their children for vaccination because they are prescribed to do so by the health workers and FCHVs, despite not being fully aware of the exact benefits.
• Supply side:
  • Facilitators: According to service providers, the supply of vaccines is largely affected by the messaging from Nepal's government. In response to the "Reaching Every Child" initiative of the NIP, Palikas (municipalities) have conducted awareness campaigns, home visits, and other initiatives to ensure no child misses vaccination. Health workers and FCHVs also described personal satisfaction and a sense of pride that comes from contributing to the community, which motivates them in their jobs. Self-confidence was observed to be a key motivator for providing quality services, including immunisation.
  • Barriers: The research revealed diminishing will of and support from Palikas to promote immunisation and uncomfortable health facility environments. Some health workers conveyed a fear to voice their concerns to authorities.
• Lack of mutual trust: Themes of mistrust and lack of mutual respect between health workers and clients, particularly those from marginalised and disadvantaged groups, were pervasive and appeared to partially explain service gaps. Lack of mutual trust could be seen in: (i) micro-aggressions (e.g., mothers felt that they were asked to wait longer for consultations because of their identity or education status), (ii) power imbalance (e.g., with mothers being reluctant to ask questions of health workers during vaccination consultations), (iii) poor quality of care (which mothers perceived at the broader health system level in Nepal), and (iv) client non-compliance and provider bias (e.g., health workers threatening mothers with legal consequences (a power they do not hold) if they did not immunise their child).

A notable finding was the relatively high levels of immunisation-related awareness, knowledge, and acceptance among caregivers. Existing social norms are highly supportive of immunisation, which respondents acknowledged as a generational shift. According to participants, girls are receiving more education today than their elders have in the past, supplying them with the knowledge to make informed decisions for their and their children's health. In fact, young mothers today are demonstrating skills in advocacy and health communication within their families and communities to encourage greater vaccine uptake, dispel myths, and alleviate lingering fears.

However, caregivers are still facing opposing views from elders in their communities and, in some cases, their own families, who discourage them from vaccinating their children because they themselves were not vaccinated and have remained in good health. Depending on the level of autonomy a woman has in her family over the decision-making for her child's health, these lingering misconceptions may impede her ability to vaccinate her child. In addition, several mothers demonstrated a tendency to comply with health worker recommendations without fully understanding the reasoning behind them. This impulse to act without asking questions threatens the sustainability of vaccine uptake, as these caregivers may be more susceptible to vaccine misinformation.

Providers themselves were also battling many issues, including the lack of support they reported receiving from the Palika authorities. Providers noted the relative absence of monitoring of their efforts, not being heard, and not having received ongoing professional training. Many were, nonetheless, passionate in their desire to increase overall vaccination rates. Indeed, their motivation to do so appears to have led some to display disapproving and even discriminatory practices toward caregivers who missed their infants' vaccinations. This "positive service bias", which may be expressed through social interactions (e.g., ignoring or speaking rudely) or service removal (e.g., threatening citizenship or school admission), may further discourage caregivers from seeking care from the health facilities.

Recommendations to emerge from the findings include:

1. Immunisation interventions should focus not on persuasion (to vaccinate), as rates are already high and attitudes favourable, but rather on the facilitation of people's desires to immunise their children. Some of those barriers are physical and structural, while others are interactional, pertaining to how providers and caregivers interact with each other.
2. Health communication messages should focus on addressing normative misperceptions about the prevalence of vaccination rates by highlighting the fact that full immunisation is the norm, not the exception, in most places. These efforts could also model the ways in which caregivers have overcome specific barriers to vaccination - e.g., by pooling childcare responsibilities so that mothers with multiple children are able to travel with the infant needing vaccinations.
3. There is a need to provide appropriately tailored training for providers. More frequent training could help providers understand the plights faced by caregivers that might account for why they have missed vaccinations, and also assist providers in adopting a compassionate, rather than a punitive, approach.
4. Building trust in the health system is key. Caregivers are more likely to use vaccination services if they feel respected by providers and the overall health system and if they can trust the quality of care they receive. In particular, greater trust is required on the part of marginalised groups who have been left out in other major health initiatives. But such trust can come only if these groups believe that the supply-side system is invested in and acting on their interest, an indication of which may be a feeling of being treated with respect when they visit health clinics.

The researchers say their "most prominent conclusion...is the influence of trust between health workers and caregivers on immunization and other service uptake....The process of building trust between the demand- and supply-sides is bi-directional, requiring effort from both groups to listen to and acknowledge each other's needs and experiences. Although it begins on an interpersonal level, we believe that building trust within Nepal's national health system may be the key factor to achieving the last stretch to full immunization."