Evaluation of Integrated Child Health Days as a Catch-Up Strategy for Immunization in Three Districts in Uganda

"What motivates me is, as a young child, our parents did not take us for ICHDs [Integrated Child Health Days] because of misconceptions that they were immunizing the uterus so that we may not have children in the future, so for those who got the chance and were vaccinated, they didn't get the diseases. However, all the children who were not immunized got sick." (caregiver, Kayunga)

Uganda's Integrated Child Health Day (ICHD) initiative aims to improve children's access to vaccinations. This evaluation aimed to understand the effectiveness of the this programme, documenting the key components of its implementation from the perspective of health managers and healthcare workers (HCWs), assessing caregivers' motivators and barriers to ICHD attendance, and estimating ICHD attendance.

The ICHDs were introduced in 2004 as part of Uganda's national strategy to strengthen routine immunisation services. They provide a comprehensive service package including the following: routine childhood vaccinations according to the national schedule; nutritional counseling; health education; vitamin A supplementation; deworming; growth monitoring; and family planning services. During the October 2022 ICHD, additional services included COVID-19 awareness and, in select districts, hepatitis B vaccination for adults.

Between October and December 2022, a mixed-methods evaluation was conducted in three districts (poor-performing Rakai, medium-performing Kayunga, and high-performing Bukedea) where ICHDs occurred. The data collection included a cross-sectional household survey of 1,432 caregivers of children under 5 years old, key informant interviews (KIIs) with 42 health managers and workers, and 9 focus group discussions (FGDs) with caregivers. The vaccines assessed were Bacillus Calmette-Guerin (BCG), oral polio (OPV), Pentavalent, pneumococcal conjugate, rotavirus (RV), and measles-rubella (MR).

The immunisation coverage based on child health cards was over 90% for all vaccines except for the second dose of RV (88.3%) and MR (16.2%). Among the children, 3.3% of the children were zero-dose; 69.4% were fully vaccinated for their age. Of the 631 children who attended ICHDs, 79.4% received at least one vaccine during the event. Although a direct association between participation in ICHDs and coverage was not found, the ICHD programme successfully provided catch-up vaccinations to 49% of the children who had missed their recommended vaccination timeline. This finding demonstrates the programme's effectiveness in reaching children who might otherwise have remained under-vaccinated, though continued efforts are needed to reach the remaining zero-dose children.

Most of the caregivers (75%) in the three districts were aware of the ICHDs. They reported attendance in April or October 2022, mainly at outreach sites, illustrating the reach of social mobilisation and communication strategies and the importance of accessibility of ICHD locations. Village Health Teams, or VHTs (49%), health workers (18.3%), and megaphone outreach (17.9%) were the primary information sources. A VHT coordinator described their role in communicating about the ICHDs in the community as follows: "If ICHDs are going to take place on a Saturday and a Sunday, we will start the mobilization on Monday because it is a big village. We can easily find out who did not [receive the message] from the megaphone; it is where we always start before coming to those who are nearer and can gather at an outreach point. For other places where caregivers always turn up, we mobilize using the local radio. We inform them about when health workers will come for immunization."

The integration of multiple child health services during ICHDs proved to be an important feature for caregivers. Among ICHD attendees, while 79.4% received vaccination services, substantial proportions also received vitamin A supplementation (48.6%) and deworming services (51.1%). FGDs revealed that this comprehensive service package was a key motivator for attendance. There was no evidence that caregivers deliberately delayed vaccination visits to coincide with additional services, suggesting that the integrated approach enhanced service uptake without creating adverse timing effects. Instead, the combination of services appeared to strengthen the overall programme attendance and acceptance, particularly in remote areas where regular healthcare access may be limited.

The FGDs revealed the following reasons for caregivers not attending ICHDs: inadequate social mobilisation, confusion caused by multiple ongoing immunisation campaigns, doubts about vaccine safety, negative HCW attitudes, and delayed and insufficient vaccine stocks. Expressing her concerns about community mobilisation, one caregiver in Kayunga was quoted as saying, in part: "what confuses me and the main reason I don't immunize is because they don't tell you which disease they are vaccinating against. But they bump into us and tell us to take the children for vaccination."

The KIIs of key health officials also revealed that Uganda's ICHDs had a wide variety of challenges that hampered effectiveness and efficiency. These included financial delays, manifesting in demotivated personnel, severe staffing shortages, and logistical difficulties in accessing remote areas. In addition, general obstacles persisted, such as a resistant public wary of vaccine safety and benefits, insufficient outreach transportation, and a shortfall in social mobilisation efforts due to a lack of communication tools and funds.

To enhance the effectiveness of the ICHD programme in Uganda, the researchers recommend, for example:
 

• A comprehensive approach focused on debunking myths and misconceptions about vaccination, including the safety of routine vaccines - This approach should be grounded in a well-structured mobilisation strategy that leverages targeted messaging. These messages, crafted with precise and comprehensive information about ICHDs, should be disseminated via trusted community figures and healthcare professionals. VHTs and HCWs play a pivotal role and should receive adequate training to convey accurate information about vaccines, their potential side effects, and management strategies for adverse reactions.
• Effective management of the scheduling of ICHDs and other vaccination campaigns - This scheduling should be planned to avoid overlap and confusion, enabling caregivers to understand the specific objectives of each campaign and the services offered.
• Incorporation of community feedback mechanisms, utilisation of mass media for broader reach, and engagement in school-based educational programmes - These strategies, combined with a focus on logistical efficiency and accessibility, especially in remote areas, could enhance the overall impact of the ICHD programme in Uganda.

In conclusion: "Despite operational challenges, ICHDs appear to have contributed to routine childhood vaccinations. Further research is needed to assess the sustainability and cost-effectiveness of the program."

Full list of authors, with institutional affiliations: Mansoor Farahani, ICAP, Columbia University; Tonny Tindyebwa; ICAP at Columbia, Kampala, Uganda; Nandita Sugandhi, ICAP, Columbia University; Kirsten Ward, U.S. Centers for Disease Control and Prevention (CDC); Youngjoo Park, CDC; Pamela Bakkabulindi, ICAP at Columbia, Kampala, Uganda; Shibani Kulkarni, CDC; Aaron Wallace, CDC; Samuel Biraro, ICAP at Columbia, Kampala, Uganda; CDC; Yvette Wibabara, CDC; Hannah Chung, ICAP, Columbia University;  Giles A. Reid, ICAP, Columbia University; Driwale Alfred, Uganda National Expanded Programme on Immunization (EPI); Rita Atugonza, EPI; Elaine J. Abrams, ICAP, Columbia University; Ledor S. Igboh, CDC