The research objectives
in the Dominican Republic were to:
- Explore perceptions, experiences and expectations
among communities concerning the provision of immunization
services (in campaigns and fixed posts).
- Determine specific problems of access to immunization
services (time, availability of services, cultural
accessibility).
- Identify other barriers to getting immunized in
routine services.
- Explore knowledge and perceptions of the immunization
card.
- Identify knowledge and perceptions about pentavalent
vaccine and motivations to receiving it.
The research objectives in Mozambique were
to:
- Explore caregivers’ perceptions, experiences
and expectations regarding the provision of vaccination
services in fixed posts and mobile brigades.
- Describe problems of access to vaccination services
in terms of time and quality of services.
- Describe health workers’ role in provision
of vaccination services in fixed posts and mobile
brigades.
- Identify the public’s sources of information
about vaccinations.
- Identify the extent of missed opportunities for
vaccination and reasons for missed opportunities.
- Explore perceptions, understanding and use of the
child health card by primary caregivers and health
workers.
Findings from the Dominican Republic and Mozambique
Key barriers: vaccine shortages and poor access
The major problem that the Dominican study revealed
was the lack of a reliable supply of vaccine in the
health facilities, except in the capital, Santo Domingo.
The mothers in all of the focus groups mentioned this
problem. In interviews, 60% of the mothers (most percentages
are rounded off) agreed that “sometimes they don’t
have the vaccine that I need.” Although 94% were
able to immunize their child the last time they tried,
three quarters of the others could not because the facility
lacked the vaccine that they needed. What one mother
said in a focus group expresses the general opinion
on this: when we arrive to have our child immunized,
the health staff says, “there is none, come back
tomorrow!”
The study found other reasons why many mothers come
to immunize their children but cannot do so or can only
with difficulty. Mothers said that at times they go
to the health post and find it closed when they arrive
(25%); 24% say that sometimes the health workers are
not there; 69% say that they have to wait a long time;
and 40% say that sometimes they do not immunize the
child because the child is sick. (This is rarely a legitimate
reason not to immunize). Some 50.5% of mothers interviewed
had arrived at a health post to get a child immunized
but could not.
In Mozambique, there were also many instances reported
where no vaccine was available (stockouts), but lack
of vaccine did not emerge as a major reason for non-immunization
or incomplete vaccination. In fact, mothers said that
the major barrier to immunization was the long distance
(difficult access) to immunization services. Almost
9% of children at least 12 months old (and over 12%
of all children in the study) had not been vaccinated
even once. Mothers of these children overwhelmingly
said the reason was difficult access to services. This
barrier is particularly important in Mozambique due
to the destruction of many health facilities during
the decades of war that ended in the early 1990s and
because of the country’s large size. Among mothers
of children behind schedule on their immunizations,
there was also a fear of side effects and evidence that
a significant number did not know when the next vaccination
was due.
There were also service-related complaints in Mozambique.
Many mothers complained of long waits. Other complaints
included: inconsistent and unpredictable hours of service;
unreliable and unpredictable outreach team visits; stock
ruptures; and missed opportunities. A number of questions
explored opportunities to inform and motivate mothers
during prenatal visits and opportunities to give BCG
after births in a health facility. Many of these opportunities
were missed.
Health staff
Many studies on immunization barriers have found that
health workers’ harsh treatment of mothers is
an important reason why they do not return to ensure
that their children complete the basic immunization
series. In the Dominican Republic study, health workers’
treatment of mothers was described as good in most sites;
in Mozambique it was extremely variable and not so good
overall. Mothers’ comments in Mozambique varied
from “we are vaccinated like dogs” to a
common opinion that they do the best job they can.
In the Dominican Republic, 97% of those interviewed
said that they had been treated well or very well and
92% of this group said they were always treated well.
There were some communication problems but they did
not appear to be serious except in one province. Most
mothers felt that health workers were: nice (97%), respectful
(95%), willing to give service (95%), kind (91%), and
informed about vaccines (83%).
In Mozambique, health workers were given an opportunity
to explain their own role in immunization. They described
their heavy work loads, low and delayed salary and per
diem payments, lack of essential supplies and equipment,
limited training opportunities and an almost total absence
of supervision. Observations and interviews showed that
health workers had low levels of knowledge on immunization;
they missed opportunities to vaccinate and educate (only
27% of child health cards examined had a vaccination
return date written); and that, particularly in certain
locations, they treated mothers poorly (41% of mothers
said that during the last vaccination visit a health
worker did or said something that made them feel uncomfortable).
Virtually none of the health workers interviewed could
identify their target population for routine vaccination,
the current year’s objective, or coverage for
the last year, although many expressed a keen desire
to learn such things.
Mothers’ opinions of health workers’
capabilities
In the Dominican Republic mothers expressed a preference
for immunization services in fixed posts and stated
that they lacked confidence in the people who vaccinate
during campaigns because “they don’t know
how to give injections” and some of them are not
regular health staff.
In Mozambique mothers also felt better about health
workers in fixed sites than in outreach sites. Most
mothers felt unqualified to judge the health staff’s
competence and assumed the workers knew their jobs.
In the Dominican Republic, responses indicated that
some health staff in fixed posts, as well as during
campaigns, follow incorrect contraindications (especially
regarding immunizing sick children) and use poor technique
in immunizing (various reports of abscesses, of immunizations
“poorly given”). In FGDs, some mothers mentioned
their fear of health staff who are so poorly prepared
that they might give the wrong vaccine.
Knowledge of diseases
Mothers in both countries had very poor knowledge about
the diseases prevented by vaccines. However, an equally
significant finding is that this low knowledge appeared
to have no significant effect on their general enthusiasm
to have their children vaccinated.
In Mozambique, only 13% of mothers could correctly
name three vaccine-preventable diseases and 57% could
not name even one. Only one in five knew that a child
is due for measles vaccination at 9 months. Only 64%
of over 800 mothers interviewed said that the main purpose
of vaccination was to protect people from diseases (others
said that immunization cures illness, helps growth,
etc.)
- In the Dominican Republic, when asked about pentavalent
vaccine, virtually all mothers liked the idea of getting
more protection with less effort (“just one
jab”). Only a small group (less than 5% in the
survey and some mothers in one focus group) were worried
that receiving five doses together might be dangerous
(too strong, might cause “attacks” or
“shock”) and cause more side effects.
- The great majority of mothers believed that meningitis
is a serious disease and more than 98% wanted their
children vaccinated against it and pneumonia. In response
to a question on what causes meningitis, over half
of respondents said falls or blows to the head and
another 30% said they did not know. The principal
motivations for seeking the pentavalent vaccine are:
protection against diseases, not having to suffer
from so many injections, and not having to go so often.
Practical knowledge about services
It is essential that each mother knows where to take
her child to be immunized and when it is time for the
next dose. In the Dominican Republic, 17% of mothers
responded that during their last visit, the health worker
did not inform them about the vaccines. The poorest
mothers sometimes had difficulty giving their child’s
precise age. This could make it more difficult to know
when to return for the next immunization.
These problems are more serious in Mozambique. Exit
interviews after vaccinations showed: 43% of mothers
were not told or could not remember the disease(s) the
vaccine was for; only about a third were told about
side effects; and a quarter were not told when to return
for the next vaccination. A review showed that on only
27% of child health cards had a health worker written
the date for the next vaccination.
The child immunization card is supposed to serve as
a key channel for information on where, when and which
vaccines are due. An important finding of the Dominican
Republic study was that without outside assistance many
mothers, even literate ones, cannot understand basic
information on the card. Eighty percent of the mothers
surveyed could read, yet only half of these literate
mothers could look at a completed vaccination card and
say:
- which vaccines the child had received
- how many immunizations the child had received or
- the date of the next immunization.
This finding is a strong argument for simplifying the
card, for teaching mothers how to interpret it and for
not depending only on the card to communicate this information.
FGDs in the Dominican Republic indicated that mothers’
not bringing the card was a problem. In the survey,
20% said that they had forgotten to take the card at
least once (but only 2.5% the last time).
In Mozambique, 87% of children had a child health card,
but only about a quarter of mothers can read. Most mothers
who said they knew the return date used methods other
than the card to remember.
Timeliness of immunizations
The studies revealed problems with timeliness of immunizations
in both countries. Of the 428 children with a card at
the time of their mothers’ interview in the Dominican
Republic, 37% had their immunizations up to date.
The Mozambican study developed a definition of “on-time”
for immunization (basically giving caregivers one month
of leeway after their child was eligible for each antigen).
By these definitions, 53% of children who use fixed
facilities were on-schedule and 39% who use mobile brigades
were on-schedule (49% overall). Immunization drop-out
rates ranged from 8% to 13% (WHO considers below 10%
as satisfactory).
Mothers’ motivation
The vast majority of mothers in both countries were
highly motivated to have their children vaccinated,
with the understanding that this would protect (prevent,
strengthen or cure) them against a number of serious
diseases. Although mothers with better knowledge were
somewhat more likely to have their children fully immunized,
there is no strong evidence that the fact that many
mothers did not know what diseases or have accurate
information about the diseases had a major influence
on their motivation.
Recommendations and Follow-up
Based on the study findings, the researchers in Mozambique
recommended that the Ministry of Health:
- Prioritize cold chain installation for all fixed
facilities
- Strengthen EPI logistics, especially the supply
of vaccines and other supplies such as needles, syringes,
and fuel
- Continue donor discussions related to expansion
of fixed and mobile services
- Intensify capacity-building for health workers,
particularly in counseling and forecasting vaccine
needs
- Improve monitoring of coverage
- Strengthen IEC efforts (focus on counseling and
communicating essential information)
- Intensify the engagement of parents, community
leaders and health agents
- Develop national guidelines for vaccination messages
(but with scope for local adaptation)
- Support improved information exchange between health
workers and mothers
- Focus on improving health card as a tool for health
workers, not mothers
The Mozambican Ministry of Health, with support from
various partners, has taken action on a number of these
steps. Insights from the study were used to develop
new communication messages and materials to promote
vaccination. In cooperation with other donors, Project
HOPE and the CHANGE Project have facilitated improvements
in immunization program logistics and procedures, supervision
from the national EPI to provinces and districts, and
the finalization of an updated EPI manual.
Project HOPE, with support from the CHANGE Project,
carried out a follow-up study on the functioning of
mobile units for immunization outreach. The study found
substantial variation in effectiveness and efficiency
and areas for improvement. While the mobile brigades
accounted for more than 20% of vaccinations, there were
many inefficiencies in planning and implementation.
Project HOPE and the CHANGE Project discussed the findings
with the Ministry of Health and other partners and drafted
simple guidelines for improving mobile brigades. They
are currently under MOH technical review.
In the Dominican Republic, the study has been followed
up by a number of actions and improvements. The study
findings were shared in meetings with health officials
throughout the country; in-service training on immunization
was given; supervision of immunization was systematized
and better funded; and an immunization manual for health
workers was completed and distributed.
At the time of the Dominican study, unreliable vaccine
supply constituted the most important barrier to improving
coverage and maintaining public confidence in the EPI.
Since this study was carried out, the reliability of
vaccine supply has improved substantially, although
it still merits careful monitoring.
Discussion
Both of these studies helped define barriers to higher
immunization coverage and provided the national immunization
programs with direction for improvements. In both countries,
it was useful to employ a combination of qualitative
and quantitative methods. Including health workers among
the groups interviewed in Mozambique provided a needed
outlet for their important voice. Examining the same
question with information from various sources and using
various methods was very useful. For example, over three
fourths of Mozambican health workers claimed to always
write the return date in the child health card, yet
an examination found such annotations in only a quarter
of the actual cards.
In both countries, despite problems with the convenience,
reliability and friendliness of services, mothers remained
highly motivated to have their children protected against
vaccine-preventable diseases. This finding,
which is consistent with those from many other studies,
implies that interventions solely aimed at increasing
demand – without accompanying improvements in
the services offered – are likely to result in
only limited increases in vaccination coverage.
Barriers related to the quality and quantity of services
play a large role in keeping coverage low. However,
there are feasible solutions to increase quality and
consistency of services. The program in the Dominican
Republic needs to continue to focus on service quality
while the program in Mozambique needs to work on both
quality and increasing the number and reliability of
fixed and outreach services. |
