Reasons for Defaulting from Childhood Immunization Program: A Qualitative Study from Hadiya Zone, Southern Ethiopia

"Minimizing the number of defaulters from immunization programs requires the concerted efforts of all stakeholders."

Ethiopia falls short of achieving the target 95% of coverage for childhood immunisation despite efforts by the government and its bilateral and multilateral partners. In analysing the challenges to achieving high coverage in Ethiopia, researchers have seen that there have been virtually no achievements in reducing dropout rates over the years. Several quantitative studies, looking at 12- to 23-month-old children, have pointed to a wide range of sociocultural, health systems, and provider-related factors that contribute to the problem. Using a qualitative approach among a younger age group (6-11 months), this study explored the issue in detail with the aim of helping develop locally appropriate, early intervention strategies to minimise defaulting from immunisation programmes.

Conducted in 2 districts of Hadiya zone, Southern Ethiopia, between November 2014 and April 2015, the study involved 26 in-depth interviews with mothers of defaulted children aged 6-11 months and key informants: Expanded Program on Immunization (EPI) focal persons of 4 health facilities selected from the 2 study districts, health extension workers from selected health posts in villages, immunisation programme managers at the zonal and district health offices, and community leaders. Observations and review of relevant documents were also conducted. Thematic analysis was used to analyse the data.

The main reason for defaulting from immunisation was inadequate counseling of mothers, which led to a lack of information about vaccination schedules and service arrangements, including in unusual circumstances such as after missed appointment, when the health workers failed to make home visits, and loss of vaccination card. The dynamics of how loss of these cards leads to dropouts is not commonly discussed, and the Ethiopian health system lacks clear guidelines on what to do when mothers show up for child vaccination without a card. It is, however, clear from the findings that cards could be lost and, in combination with other factors, such as negative perceptions toward health workers and lack of knowledge on what to do under these circumstances, mothers failed to return to health facilities for child vaccination services or are actually denied the service when tried to seek help after a lost vaccination card.

In general, several mothers stated that the advice they received from health care providers was minimal; one of the mothers said: "...Other than the appointment date, they never told me anything about the type of vaccine, including for what reason they give the vaccines. They only tell us to have our children vaccinated. Sometimes they come to our home and provide vaccines to children without telling us what they gave to the children and why." One of the EPI focal persons also expressed concern regarding counseling by health workers, observing that, "in some cases, health workers do not deliver all the necessary messages to mothers." Provider-client relationships are poor, with mothers reporting fear of mistreatment and lack of cooperation from service providers.

Contrary to what health workers and managers believe, mothers were knowledgeable about the benefits of vaccination; what they do lack knowledge on is the various operational aspects of the service, especially the schedules and options to obtain the services in case of missed appointment or lost vaccination card. The high workload on mothers compounded by the lack of support from male partners - caring for children, including the responsibility to take them to health facilities, is entirely the women's role in their culture - was also found to contribute to the problem. Health system factors of note included poorly arranged and coordinated immunisation services, vaccine and supplies stockouts, and lack of viable defaulter tracking systems in the health facilities.

In conclusion: "Counseling of mothers on vaccination should be standardized and strengthened and address key issues, including the schedules, service arrangements and commonly encountered circumstances that could prevent mothers from seeking the service. Mothers should be properly advised on the steps they need to take if they travelled to other locations, lost vaccination cards, children had side effects after immunization, or they missed appointment for any reason. Health workers need to be supportive of mothers. Awareness raising to empower women and increasing male involvement in child immunization are also important. Arrangements and coordination of immunization services need particular attention, especially in terms of coordinating static and outreach services to avoid possible confusion. Ensuring sustained supply of vaccines and instituting effective referral linkages and defaulter tracking mechanisms would also be vital. Defaulter tracing could be improved by leveraging the existing community structures, creating mechanisms for monitoring the activity, ensuring accountability, and learning from the rich experience of HIV care and treatment program."