Nearly three years into the coronavirus pandemic, our global push for routine immunizations has been sluggish; 25 million children under 1 year did not complete all of their recommended vaccines in 2021 – the highest number since 2009. As we’ve redirected our resources to address COVID-19, children around the world – particularly those in low-resource settings – have missed out.
There’s reason to be optimistic about reaching pre-pandemic routine immunization levels. Many organizations are propelling strategies that target missed communities and are doubling efforts to solve inequity in immunizations.
At VillageReach, we’re building on what we know works, increasing immunizations for the hardest-to-reach communities through people-centered solutions. Our Bate-Papo Vacina! (“Let’s Talk about Vaccines!”) program is developing immunization solutions for communities in Mozambique and Malawi by engaging with caregivers of fully- and of partially-vaccinated children to capture their stories and elevate their voices and experiences.
Placing health worker and caregiver voices at the center of our work
Collaborating with the Zambézia Provincial Health Department in Mozambique, we conducted a participatory study in late 2020 and early 2021 that engaged health workers and caregivers of children between the ages of 25-34 months to understand the barriers that prevent full vaccination.
Hearing their stories allowed us to identify trends and understand the unique contextual landscape of Mozambique – social, political and geographic – which is critical to building community-driven solutions to improve under-two routine vaccination.
We hired and trained four local caregivers to co-conduct the research. Our participatory approaches gave caregiver and health worker participants the opportunity to reflect on findings and co-create solutions. Our study had three phases – photovoice, live messaging and semi-structured interview and human-centered design workshops.
Success factors that support full vaccination
Although we identified barriers that limit full vaccination of children under-two, we also explored the contexts and motivations that facilitate complete vaccination. By addressing barriers and amplifying successes, we can support future immunization programs in Mozambique and similar contexts.
Social network support
In Mozambique, it is primarily the responsibility of the mother to take her child to receive routine immunizations. Our research indicated that women who have support from their spouses at home, their family and their community have greater success at achieving full vaccination for their families. These support networks have helped mothers by reminding the them of vaccination dates, providing childcare, helping with household duties, caring for the child post-vaccination, providing transportation (e.g. a motorbike ride) or funds for transportation to the health post and accompanying the mother to the health post so she wouldn’t have to travel alone.
One mother shared the role her husband played in supporting her children’s vaccinations.
“When I go to the hospital, [the child’s father] takes me on the motorbike and after the vaccination sessions, he helps me calm the child down…There are fathers who leave everything [to mothers], claiming that [the mother] is the one who took the child for vaccination and [the mother] must bear the consequences. So [the above photo] was to show fathers that it is important to help a mother after she comes back from the vaccination [session] by calming the child down to allow the mother(s) to cook meals, and taking the opportunity to check the child’s situation in vaccination…It is important for fathers to get involved in the process. If mothers don’t know the dates, fathers should always remind [mothers]…Every time I came back from the hospital I updated [my husband] on the next date in order for him to remind me in case I forgot it.”
Health motivations
For the majority of the mothers we interviewed, the primary motivation to vaccinate is to ensure their children are happy and healthy. Many mothers shared examples of seeing other children in their communities who were unvaccinated and suffered diseases like polio and measles. These mothers felt that completing the vaccination sequence was a priority, even if it meant that their children might experience side-effects such as fevers, swelling, or tiredness; the life-long benefits of vaccination outweighed the risk of short-term side-effects.
For one parent, protection from disease is the ultimate motivator to vaccinate her child. Despite sometimes challenging side-effects, she is comforted that the vaccine will support her daughter’s overall health.
“It is not that the child is swollen for a long time; it does not last seven days with a swollen leg; it swells and then it reduces. And we start to see the child healthy, and we start to rejoice to see this child… So, when I go to the hospital, even if my daughter’s leg swells, I don’t get demoralized, because afterwards she will be better. I don’t act like, ‘if my daughter has a swollen leg, I can’t go back to the hospital.’ This is a mistake that mothers make.”
Practical reminders
Immunization cards are provided to caregivers at each appointment. These track the immunizations and record the date for the next vaccine. For caregivers, these have been a useful resource to keep track of upcoming appointments and to easily see how many vaccines their children still need to receive before they are fully vaccinated. Some caregivers also show these cards to their spouses or other family members to keep them updated on their children’s health.
A mother, pictured below, described how useful the immunization cards have been while getting her child vaccinated.
“Every month on the scheduled dates I had to take my child’s vaccination along with her card…When taking the child to the vaccine, it is important to take the card, because through the card they identify the child’s name, the vaccines and the dates of the next appointments.”
Applying what we’ve learned
From these caregiver experiences, we’ve identified a solution to address the barriers and strengthen the motivations for routine childhood vaccinations in Mozambique.
We’re working with district health authorities, community health workers (CHWs) or Agentes Polivalentes Elementares (APEs), health care workers (HCWs) and community leaders in Namarroi and Gile Districts in Zambézia Province, Mozambique to improve immunization completion. The solution will be piloted for one year and has three main components – immunization education with targeted messages, mobile brigade prioritization and collaborative immunization activity planning.