Barriers and Opportunities for Improving Childhood Immunization Coverage in Slums: A Qualitative Study

"Effective communication at different levels and consideration of factors especially at the receiver end is essential to strengthen routine immunization uptake."

Slum dwellers, who make up nearly 33% (100 million) of India's urban population, are characterised as being particularly vulnerable to outbreaks of vaccine-preventable disease (VPD). Noting the limitations of quantitative research on immunisation, these researchers pursued a multi-level qualitative approach to enable real-time interactions with stakeholders who form a principal element of any immunisation programme. Their goal was to explore major barriers, potential opportunities, and key facilitators of childhood immunisation in slums in Mumbai, India.

Within 55 slum health posts, the researchers conducted 10 non-participatory observations (NPOs) of immunisation sessions and in-depth interviews (IDIs) of 65 people (e.g., influencers in the family, healthcare service providers, and policymakers).

The NPOs exposed some weaknesses that have communication-related implications. For example, it was observed that specific instructions for the vaccine the child received was not provided to mothers or caregivers. They were given limited information with respect to the next immunisation and the possibility of adverse events following immunisation (AEFIs). Immunisation-related information displayed on the walls at health facilities was outdated. Also, the attitude of healthcare workers towards the beneficiaries was quite variable: Some were warm and friendly, but the majority of them were authoritative and demonstrated lack of empathy.

According to the researchers, there is a potential scope for improvement and creating awareness with respect to immunisation, its importance, the diseases vaccines prevent, and the overall benefits to the child by replacing the old, outdated immunisation-related display materials. Self-playing videos in local languages on various health topics including immunisation could generate more interests among mothers and caregivers during their waiting time for the immunisation. Health talks by service providers on VPDs, immunisation, nutrition, etc. during pre- and post-immunisation sessions could create awareness among caregivers. Healthcare services imbued with emotion and a personal touch could strengthen the relationship between the healthcare service provider and the beneficiary. Sensitising healthcare service providers about their contribution to improving immunisation coverage could be motivating.

The majority (93%) of the 50 influencers in the family who were interviewed did not have any idea about VPDs, though they knew about polio drops and to some extent about an injection that left a scar on the left upper arm (they did not know that it was Bacillus Calmette Guerin (BCG) vaccine). Participants said they received immunisation-related information from relatives, neighbours, television, or newspapers. They were aware of the vaccination centres and also informed or advised others (e.g., neighbours, friends) to get their children vaccinated. Limited free time, lack of awareness, long waiting hours, fear of adverse events, and concerns related to loss of daily income were some of the major challenges or reasons for not getting their children vaccinated. Also, poor/rude behaviour of staff was an important factor that led to either delayed or missed immunisation.

Most of the influencers felt that current situation could be addressed by: improving condition of healthcare facilities; strengthening trust between healthcare service providers and beneficiaries; bringing accountability and emotions in the healthcare services; involving communities during immunisation services; creating ongoing awareness among parents and caregivers (conducting various campaigns similar to that for the pulse polio programme); offering incentives for providing and getting immunisation services; sending text messages to remind caregivers about upcoming/pending doses; ensuring timeliness, completeness, and quality in services; and seeking community feedback on immunisation services.

In addition, 15 key officials at various levels were interviewed using a pre-structured questionnaire. They were asked a series of questions, with responses shared in the article:

• Do service providers and beneficiaries understand VPDs, vaccines, and importance of vaccination specific to slum settings? One response: Auxiliary nurse midwives, supervisors and other service providers are trained, accountable and responsible to vaccinate.
• How are slums different from other settings in terms of people, VPDs, and its prevention through vaccination? One response: For those living in poverty, there are priorities more pressing than immunisation.
• How do slums populations view vaccination - their perception about VPDs, vaccines, and vaccination? One response: Campaigns like pulse polio and Mission Indradhanush have played an important role in improving awareness.
• What are the reasons for vaccinating or not vaccinating? One response: Because of work schedules, a major barrier is finding a way to take the child to the immunisation centre.
• What are the major challenges? One response (on the demand side): Less community participation; thus, immunisation is still not owned by the people living in these settings.
• What are the opportunities available to improve coverage? One response (on the demand side): Provide recognition or reward to those villages or communities having active participation and considerable immunisation coverage.
• What are the expectations from the beneficiary, community, service provider/policymaker? One suggestion: Bring government, non-governmental organisations (NGOs), academic bodies, research institutions, professional bodies (Indian Academy of Pediatrics (IAP), Indian Medical Association (IMA), etc.), medical colleges, and civic bodies together on a common platform to discuss how to improve immunisation coverage in the slums.

In conclusion: "Immunization is a shared responsibility involving community, healthcare service providers, policy makers, and parents who are active participants in the process."