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Fig. Map of Dhaka city and Zone 3
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Introduction
Coronavirus disease 2019 (COVID-19) vaccination has emerged as a promising approach to counter the harmful impacts of the pandemic. Understanding the psychological components that may impact an individual's attitude toward COVID-19 vaccination is crucial for generating evidence-based ways to minimize vaccine hesitancy. This study deter...
The first COVID-19 case in Bangladesh was detected on March 8, 2020. Since then, efforts are being made across the country to raise awareness among the population for preventing the spread of this virus. We aimed to examine the urban slum dwellers’ knowledge, attitude, and practice (KAP) towards COVID-19 transmission-prevention. A phone-based cross...
Citations
... Barriers to and facilitators of immunization exist on both the supply-side (which includes logistics, such as cold chain management) and the demand-side (which includes access to and affordability of vaccines and psychosocial factors like fear and acceptance) [8]. On the demand-side, several health service-related behaviors of parents and caregivers are associated with greater immunization uptake, including retaining the child's immunization card [9][10][11], obtaining services at privately-owned facilities [10], and giving birth in an institutional setting [9,12]. Institutional delivery is particularly correlated with immunization coverage, as health workers can more readily administer the first scheduled vaccine (BCG) immediately after birth than in a home setting [9,12]. ...
... Awareness of the vaccine schedule is a crucial aspect of parent knowledge [10,11,13]. Nepal requires seven separate visits over 15 months to complete the full schedule [12]. ...
... Immunization may be hindered by several factors, including parental fear and health system barriers. Several studies suggest that parental fear could be contributing to low immunization rates by creating poor perceptions of vaccines [11][12][13][14][15]. Both in the US and globally, parents have reported considerable distrust in vaccines, which has created a pattern of vaccine hesitancy [16,17]. ...
Background
Approximately 35% of Nepal’s children have not received all recommended vaccines, and barriers to immunization exist on both the demand- (i.e., access, affordability, acceptance) and supply- (i.e., logistics, infrastructure) sides.
Objective
This article describes a formative study to understand the barriers to and facilitators of immunization in Makwanpur, Nepal from both the demand- and supply-sides.
Methods
Through in-depth interviews, key informant interviews, and focus group discussions ( N = 76), we assessed knowledge, attitudes, and experiences with immunization; social norms related to immunization; perceptions of local health facilities; and descriptions of client-provider relationships. Data were analyzed using an iterative, grounded theory approach.
Results
Three major themes emerged, including positive demand of vaccines, lack of mutual trust between service seekers and service providers, and internal and external motivators of vaccine supply. On the demand-side, caregivers reported high levels of immunization-related awareness, knowledge, and acceptance, largely perceived to be due to a generational shift. On the supply-side, providers expressed passion for their work despite lack of support from local authorities and a desire for more training. Between caregivers and providers, lack of mutual trust emerged as a prominent barrier, revealing a cycle of positive service bias.
Conclusions
We identified mutual trust as a key pathway toward reaching full immunization coverage in Nepal and we recommend future interventions adopt an approach which focuses on removing social barriers (i.e., distrust) and structural barriers (i.e., opening hours, neglected infrastructure) to immunization.
... Multiple studies in Asia and Africa have found a positive association between parental knowledge of immunization and vaccine uptake (Odusanya et al., 2008;Owino et al., 2009;Perry et al., 2020). This can refer to knowledge about the purpose of vaccines, appropriate ages to receive specific vaccines, age at which a child should complete the vaccines, and symptoms of vaccines, among other topics (Odusanya et al., 2008). ...
... For countries like Nepal that rely on immunization cards to track children's vaccine records, immunization card retention is a major facilitator of uptake (Acharya et al., 2019;Perry et al., 2020). Perry et al. (2020) found that in Bangladesh where, like Nepal, immunization cards are required to receive vaccines, parents are met with anger, shouting, and in some cases a fee when they lose or forget their card. ...
... For countries like Nepal that rely on immunization cards to track children's vaccine records, immunization card retention is a major facilitator of uptake (Acharya et al., 2019;Perry et al., 2020). Perry et al. (2020) found that in Bangladesh where, like Nepal, immunization cards are required to receive vaccines, parents are met with anger, shouting, and in some cases a fee when they lose or forget their card. Improving immunization card retention has serious implications for encouraging immunization in Nepal, where the retention rate for immunization cards is only 52% (Acharya et al., 2019). ...
Background: Each year, 600,000 children under 5 years old die from vaccine-preventable diseases globally. Immunization is an effective way to prevent many diseases, saving two to three million lives per year. The Nepal National Government recommends vaccinations for all children for 11 diseases by 15 months of age. However, only 78% of children between 1-2 years of age have received all recommended vaccines and only 43% receive them at the age-appropriate times for which they are scheduled.
Objectives: This protocol describes the development of an intervention – called “Rejoice Architecture” – that is informed by three theoretical perspectives: choice architecture, the broken windows theory, and the theory of normative social behavior. We also describe a mixed-methods approach to develop the intervention, which will improve the physical and social environments of health facilities in Makwanpur, Nepal. We hypothesize this intervention will improve immunization behaviors and intentions among mothers of children younger than 2 years, pregnant women, and prospective mothers.
Methods: We describe the qualitative formative assessment to understand existing attitudes, norms, and behaviors among caregivers, healthcare workers, and government representatives. The formative assessment will include in-depth interviews, key informant interviews, and focus group discussions. We also describe the overall quasi-experimental study design, used to assess intervention impact.
Impact: This study will contribute to the social and behavioral change communication intervention research by offering a novel strategy for increasing immunization. This study will also illustrate to policymakers the value of structural change for health service delivery.
... It might also lead to postponing the date of vaccination, which was an important predictor of incomplete immunization in a case-controlstudy carried out in Ethiopia [34]. Studies have shown that fear of side effects was found as an important factor leading to under-immunization [25, [35][36][37]. A review of the gray literature [24] has also shown that perceived efficacy is one of the major reasons behind under-vaccination. ...
Background
Immunization is one of the most effective health interventions averting an estimated 2–3 million deaths every year. In Nepal, as in most low-income countries, infants are immunized with standard WHO recommended vaccines. However, 16.4 % of children did not receive complete immunization by 12 months of age in Nepal in 2011. Studies from different parts of the world showed that incomplete immunization is even higher in slums. The objective of this study was to identify the predictors of incompletion of immunization among children aged 12–23 months living in the slums of Kathmandu Valley, Nepal. Methods
The unmatched case-control study was conducted in 22 randomly selected slums of Kathmandu Valley. The sampling frame was first identified by complete enumeration of entire households of the study area from which 59 incompletely immunized children as cases and 177 completely immunized children as controls were chosen randomly in 1:3 ratio. Data were collected from the primary caretakers of the children. Backward logistic regression with 95 % confidence interval and adjusted odds ratio (AOR) were applied to assess the factors independently associated with incomplete immunization. ResultTwenty-six percent of the children were incompletely vaccinated. The coverage of BCG vaccine was 95.0 % while it was 80.5 % for measles vaccine. The significant predictors of incomplete immunization were the home delivery of a child, the family residing on rent, a primary caretaker with poor knowledge about the schedule of vaccination and negative perception towards vaccinating a sick child, conflicting priorities, and development of abscess following immunization. Conclusion
Reduction of abscess formation rate can be a potential way to improve immunization rates. Community health volunteers should increase their follow-up on children born at home and those living in rent. Health institutions and volunteers should be influential in creating awareness about immunization, its schedule, and post-vaccination side effects.
... Les quelques études sur la vaccination consacrées au milieu urbain concernent beaucoup plus des recherches sur les pays développées (Markland and Durand 1976;McConnochie and Roghmann 1992;Ozkaya et al. 2011) ou des études concernant les stratégies globales pour l'amélioration de la vaccination des enfants dans les villes (Atkinson and Cheyne 1994). Quelques travaux de recherche relativement récents se sont intéressées à l'étude de la vaccination des enfants dans les villes des pays en développement, mais les questions de disparités et l'impact de la migration ne constituent pas toujours les problématiques de recherche (Borus 2004;Perry et al. 2007;Ubajaka et al. 2012). Les recherches sur les relations migration-vaccination des enfants en Afrique représentent une proportion relativement marginale des productions scientifiques consacrées à la problématique globale de la vaccination. ...
Dans la perspective de contribuer au débat scientifique sur les enjeux sanitaires urbains et les facteurs d’influence, l’objectif général de cette étude est d’analyser le rôle et les mécanismes à travers lesquels la migration, la pauvreté et l’environnement de vie contribuent à l’hétérogénéité des situations sanitaires et à la production d’inégalités urbaines de santé des enfants à Ouagadougou au Burkina Faso. Sur la base de données longitudinales prospectives, de modèles d’analyses biographiques, de régressions de sélection de Heckman et multiniveaux, l’étude cherche à cerner non pas l’état sanitaire général prévalant dans cette ville, mais des situations sanitaires qui refléteraient la pluralité ou les disparités intra-urbaines de santé des enfants, en termes de poids à la naissance, de statut vaccinal et de mortalité avant l’âge de cinq ans. Tout en nuançant l’avantage sanitaire urbain général, il s’agit à travers cette étude de contribuer à accroître la prise de conscience des politiques sur la pluralité et les iniquités urbaines de santé des enfants, afin que des programmes de santé adéquats et adaptés à la fois à l’ampleur et à la diversité des besoins puissent être éventuellement développés dans une perspective d’équité.
... Fig. 2 Map of the number of quotes on concerns by country and type of concern from qualitative studies in the systematic review on concerns about vaccination in low-and middle-income countries Nine studies reported concerns related to minor side effects, to which they attributed a significant impact on vaccination behaviour. Perry et al. concluded in their study in Bangladesh: ''a number of mothers mentioned that their children had developed fever, swelling at the injection site, or had otherwise become sick after immunisation and they, therefore, did not want to take their children back for any further immunisations'' (Perry et al. 2007). Quantitative studies found that this reason was less prominent [between 1.1 and 18.8 % among people with negative views about vaccination or with a child partially or totally unimmunised (Babalola 2011;Naeem et al. 2012b;Torun et al. 2008)]. ...
... One mother participating in a FGD in Burkina Faso explained: ''The health care worker shouts, is arrogant, argues, makes a fuss, is ill-tempered, uses awkward words and scolds you'' (Sia et al. 2011). As concluded by Perry et al. in their study in Bangladesh: ''The fear of being 'scolded' by the vaccinator after losing the immunisation card (a not uncommon event), and the necessity of having to pay to obtain a new one'' was one of the major barriers to access vaccination services (Etokidem and Wondifon 2013;Perry et al. 2007). Some mothers feared going to the health facility for vaccination if they did not have a good enough ''baby shawl'' to carry the baby. ...
Objectives:
Concerns about vaccination lead to under- and no-vaccination. Our objective is to synthesise and expose evidence on individuals' and communities' concerns about vaccination to influence current debates on strategies to improve vaccination coverage in low- and middle-income countries.
Methods:
Systematic literature review till February 2014, following standard methods. Published and grey literature that focused on individuals and community concerns on childhood vaccinations were selected.
Results:
44 quantitative, qualitative and mixed-methods studies were included. Main reported concerns referred to perceptions of vaccine harms (e.g. attribution of fatal events). Other concerns included programme distrust (mainly due to rumours and conspiracies) and health system unfriendliness.
Conclusions:
Concerns about vaccination are widespread and further worsen the challenges related to programmatic and health system barriers to vaccination. There is a disconnection between qualitative and quantitative research which misses the opportunity to quantify what is reported in the former. Strikingly, there is a wealth of evidence on concerns but much lesser evidence on interventions to address them. We welcome World Health Organization initiative to tackle vaccine hesitancy and call for the synthesis of evidence and production of guidance on strategies to address concerns on vaccination.
... Studies on the reasons for low immunization coverage from a variety of countries have identified such factors as inadequate immunization services, poor parental knowledge and attitudes, limited access to services, poor health staff attitudes and practices, unreliability of services, false contraindications, fears of side effects, conflicting priorities, and parental beliefs. [14][15][16][17] Similarly, this study indicates that poor immunization coverage in Dili is related to multiple, complex, and interrelated factors, including inconsistent and irregular immunization sessions, lack of adequate outreach activities, and some health care workers' poor behavior toward clients, which leads mothers to fear being reprimanded. Underlying these factors is the health system's problems in providing adequate resources to facilities to conduct the full range of services, including integrated outreach services. ...
... Studies have found that extended hours can reduce dropouts and left-outs in urban areas. 16,23 In addition, making services more reliable, for example, by having regular stocks of vaccines, is crucial to ensuring the community's faith in service delivery. ...
Background:
Timor-Leste's immunization coverage is among the poorest in Asia. The 2009/2010 Demographic and Health Survey found that complete vaccination coverage in urban areas, at 47.7%, was lower than in rural areas, at 54.1%. The city of Dili, the capital of Timor-Leste, had even lower coverage (43.4%) than the national urban average.
Objective:
To better understand the service- and user-related factors that account for low vaccination coverage in urban Dili, despite high literacy rates and relatively good access to immunization services and communication media.
Methods:
A mixed-methods (mainly qualitative) study, conducted in 5 urban sub-districts of Dili, involved in-depth interviews with18 Ministry of Health staff and 6 community leaders, 83 observations of immunization encounters, 37 exit interviews with infants' caregivers at 11 vaccination sites, and 11 focus group discussions with 70 caregivers of vaccination-eligible children ages 6 to 23 months.
Results:
The main reasons for low vaccination rates in urban Dili included caregivers' knowledge, attitudes, and perceptions as well as barriers at immunization service sites. Other important factors were access to services and information, particularly in the city periphery, health workers' attitudes and practices, caregivers' fears of side effects, conflicting priorities, large family size, lack of support from husbands and paternal grandmothers, and seasonal migration.
Conclusion:
Good access to health facilities or health services does not necessarily translate into uptake of immunization services. The reasons are complex and multifaceted but in general relate to the health services' insufficient understanding of and attention to their clients' needs. Almost all families in Dili would be motivated to have their children immunized if services were convenient, reliable, friendly, and informative.
... For example, Blanchet described insulting treatment of mothers in urban Dhaka in 1991. 14 Although clearly there have been changes in Bangladesh in the last 20 years, Khan in 2005 15 and Perry et al. in 2007 51 reported similar behavior by health staff in Dhaka. Perry, in 1996, 16 however, reported that mothers in Dhaka considered providers in general to be knowledgeable and friendly. ...
In collaboration with WHO, IMMUNIZATION basics analyzed 126 documents from the global grey literature to identify reasons why eligible children had incomplete or no vaccinations. The main reasons for under-vaccination were related to immunization services and to parental knowledge and attitudes. The most frequently cited factors were: access to services, health staff attitudes and practices, reliability of services, false contraindications, parents' practical knowledge of vaccination, fear of side effects, conflicting priorities and parental beliefs. Some family demographic characteristics were strong, but underlying, risk factors for under-vaccination. Studies must be well designed to capture a complete picture of the simultaneous causes of under-vaccination and to avoid biased results. Although the grey literature contains studies of varying quality, it includes many well-designed studies. Every immunization program should strive to provide quality services that are accessible, convenient, reliable, friendly, affordable and acceptable, and should solicit feedback from families and community leaders. Every program should monitor missed and under-vaccinated children and assess and address the causes. Although global reviews, such as this one, can play a useful role in identifying key questions for local study, local enquiry and follow-up remain essential.
... For example, Blanchet described insulting treatment of mothers in urban Dhaka in 1991. 14 Although clearly there have been changes in Bangladesh in the last 20 years, Khan in 2005 15 and Perry et al. in 2007 51 reported similar behavior by health staff in Dhaka. Perry, in 1996, 16 however, reported that mothers in Dhaka considered providers in general to be knowledgeable and friendly. ...
In collaboration with WHO, IMMUNIZATIONbasics analyzed 126 documents from the global grey literature to identify reasons why eligible children had incomplete or no vaccinations. The main reasons for under-vaccination were related to immunization services and to parental knowledge and attitudes. The most frequently cited factors were: access to services , health staff attitudes and practices, reliability of services, false contraindications, parents' practical knowledge of vaccination, fear of side effects, conflicting priorities and parental beliefs. Some family demographic characteristics were strong, but underlying, risk factors for under-vaccination. Studies must be well designed to capture a complete picture of the simultaneous causes of under-vaccination and to avoid biased results. Although the grey literature contains studies of varying quality, it includes many well-designed studies. Every immunization program should strive to provide quality services that are accessible , convenient, reliable, friendly, affordable and acceptable, and should solicit feedback from families and community leaders. Every program should monitor missed and under-vaccinated children and assess and address the causes. Although global reviews, such as this one, can play a useful role in identifying key questions for local study, local enquiry and follow-up remain essential.
... Bangladesh has experienced one of the highest urban population growth rates in the last 3 decades, at >6% per year, which compares with a national population growth rate of about 1.5% per year (Perry et al. 2007). Employment, shelter and basic services accessible to the growing number of urban poor have become a major socio-economic and policy issue in Bangladesh (Islam et al. 1997;Khanam et al. 2002). ...
This community-based cross-sectional study was conducted in Dhaka city over a 12-month period from June 2007 to May 2008. The study population included ever-married females and males aged 15-49 years. Data for the study were collected through a community survey and exit interviews. Both bivariate and multivariate analyses were done. Seventy-two per cent of female and 48% of male street-dwellers interviewed were sick at the time of data collection. Twenty-one per cent of deliveries were conducted on the street. Eighty-nine per cent of the street-dwellers reported that their children aged less than 5 years had more than one symptom associated with acute respiratory infection during the last 2 weeks. Thirty-seven per cent of the females and 34% of the males interviewed reported that their accompanied children had diarrhoea. A few street-dwellers sought services for their health problems, and most went to the nearest pharmacy and to mobile clinics run by a non-governmental organization at night. Eighty-eight per cent of the female and 88% of the male street-dwellers used open space for their defecation. The street-dwellers are extremely vulnerable in terms of their health needs and health-care-seeking behaviours. There is no health service delivery mechanism targeting this marginalized group of people. Although the health, nutrition and population sector programme of Bangladesh designed programmes to ensure equitable essential services to all, this marginalized group of people was not targeted. The Ministry of Health and Family Welfare and private sectors should, thus, should focus future programmes to meet the needs of this extremely vulnerable group. Mobile and static clinics at night for street-dwellers may be potential programmes. Action research to assess the effectiveness of programmes is essential before large-scale implementation.
Background
Many children in low and middle-income countries remain unvaccinated, and vaccines do not always produce immunity. Extensive research has sought to understand why, but most studies have been limited in breadth and depth. This study documents existing evidence on determinants of vaccination and immunization and presents a conceptual framework of determinants. Methods
We used systematic review, content analysis, thematic analysis and interpretive synthesis to document and analyze the existing evidence on determinants of childhood vaccination and immunization. ResultsWe documented 1609 articles, including content analysis of 78 articles. Three major thematic models were described in the context of one another. Interpretive synthesis identified similarities and differences between studies, resulting in a conceptual framework with three principal vaccine utilization determinants: 1) Intent to Vaccinate, 2) Community Access and 3) Health Facility Readiness. Conclusion
This study presents the most comprehensive systematic review of vaccine determinants to date. The conceptual framework represents a synthesis of multiple existing frameworks, is applicable in low and middle-income countries, and is quantitatively testable. Future researchers can use these results to develop competing conceptual frameworks, or to analyze data in a theoretically-grounded way. This review enables better research in the future, further understanding of immunization determinants, and greater progress against vaccine preventable diseases around the world.
