Burden of Zero-Dose Children in Pastoralist, Hard-to-Reach and Underserved Communities: A Case Study of Mubende District, Uganda

"[Q]ualitative insights were gained from participatory dialogues and IDIs with caregivers of zero dose children providing an in depth understanding of key contextual issues that need to be taken into consideration when addressing the zero-dose problem."

In Uganda, strategies like radio talk shows, mass campaigns, and static and outreach programmes have been adopted to address socio-cultural practices that discourage immunisation and negative beliefs and attitudes towards immunisation. Although these efforts have led to increases in vaccination coverage, many children in the country remain under/unimmunised. To support the effective design and implementation of context-specific interventions that foster equity, this study by the Uganda Learning Hub for Immunisation Equity (LH) sought to characterise zero-dose children (ZDC), under-immunised (UI) children, and missed communities in Uganda and to understand the barriers and challenges to identifying and reaching them.

Immunisation in the country is managed by the Uganda National Expanded Program on Immunisation (UNEPI) with support from partners. This evaluation and learnings are intended to inform UNEPI about the interventions that work well and should be scaled up to other districts and to identify those that are not working that may need to be adjusted or dropped.

The LH conducted a cross-sectional, mixed-methods targeted community survey from March to August 2024 in three high-risk communities (HRCs) in Mubende district (i.e., underserved community in Kiruuma sub-county, hard-to-reach community in Butoloogo sub-county, and pastoral community in Kigando sub-county). Selecting three unique HRCs allows for extrapolation to similar areas in Uganda.

The study population included children aged 4.5 to 23 months, and the respondents in the survey were the mothers/primary caregivers of the children. To gain better understanding of the survey findings, two participant dialogues were conducted with village health team (VHT) members, and 19 in-depth interviews were conducted with mothers/caregivers of ZDC. Data were analysed manually using a root cause analysis approach.

The study found that the overall burden of ZDC in the surveyed communities was 12.7% (i.e., 17.9% in the underserved community, 15.9% in the pastoral community, and 4.9% in the hard-to-reach community), while the UI burden was 7.1% (i.e., 33.6% in the underserved community, 38% in the pastoralist community, and 12.3% in the hard-to-reach community). The odds of being ZDC were 2 times higher when the grandparents were the primary caregivers compared to when the mother was the primary caregiver, and children born in the community (at home or with assistance of traditional birth attendants (TBAs)) had more than twice the odds of being ZDC as compared to children born in public facilities. Physical access for immunisation services may not be a major barrier to seeking immunisation services, as there were households with ZDC and UIC that were located within 3.2 kilometres of the nearest health facility.

The key barriers to ZDC accessing immunisation services were:

• Caregivers who are not the mothers of the children, especially the grandparents, prioritising providing for other basic needs over immunisation;
• Negative health workers attitude (health workers scolding caregivers for misplacing vaccination cards, missing appointments, and poor dressing);
• Knowledge gaps on immunisation among caregivers (some caregivers not knowing the immunisation schedule and generally not appreciating the need for immunisation);
• Fear of side effects and adverse events following immunisation (AEFIs);
• Language barriers by immigrants from Rwanda, which hindered them from seeking immunisation services;
• Poor health of some mothers, which hindered them from seeking immunisation services;
• Family disruption (e.g., marital problems), which makes it challenging to track the child's immunisation status;
• Family tradition (family not immunising);
• Children undergoing treatment for special conditions such as club foot, who had been advised to delay vaccination;
• In some cases, long distance to health facilities and outreach posts; and
• Gender dynamics, where immunisation is perceived as a woman's role (contextual barrier). There was limited or no involvement of men when it came to immunisation in this setting. This finding points to the need for gender-responsive interventions that consider the specific challenges faced by women.

Thus, the findings emphasise the importance of targeted outreach, efforts to improve health worker attitudes, caregiver education, and work to strengthen health infrastructure and data systems to close the immunisation gap and ensure no child is left behind. In short, zero dose is a complex problem embedded in cultural and family dynamics; therefore, community structures are key in identifying and reaching ZDC.

Recommendations include:

In the near term:

• National and sub-national (district) stakeholders should support health facilities to conduct more outreach frequently and consistently, especially in underserved areas, such as Kiruuma sub-county.
• During social mobilisation for immunisation, community health structures such as VHTs should look out for children: (i) who are under the care of non-biological parents; (iii) who are born in the community (TBA/home); (iii) who have caregivers with prolonged illnesses and (iv) whose parents are not staying together - as these children are at a higher risk of missing out on immunisation services.
• Because caregivers consider health workers to be an authentic and reliable authority regarding health-related matters, health workers and VHTs should enhance community sensitisation about (i) the importance of immunisation; (ii) vaccine-preventable diseases; (iii) Uganda's immunisation schedule; (iv) where to access immunisation; and (v) anticipated side effects of vaccination and how to manage them.

In the medium term:

• National stakeholders should support the sub-national (Mubende district) to:
  • Expand services to high-risk communities, especially in underserved areas such as Kiruuma sub-county, through the construction of more health facilities within the communities.
  • Upgrade existing lower-level health facilities to higher service-delivery levels so that they can meet the high demand for immunisation services.
• Future studies should:
  • Investigate reasons for poor health worker attitudes (the findings may provide evidence on how to better improve health worker attitudes to ensure client-centred care).
  • Explore the role of gender in immunisation uptake.
• There is a need for a digital data capture system that collects information at both community and health facility levels to enable timely and a more accurate identification of ZD and UI children. This system will also minimise reliance on immunisation cards to track the child's immunisation status.