Evaluation of the Drivers of Urban Immunisation in Uganda: A Case Study of Kampala City

"...findings indicate that inadequate information on and knowledge of immunisation among caregivers is a key barrier to full immunisation of children in Kampala city. In the urban context where people have rapid and widespread access to information from various sources including social media, misconceptions are more likely to occur."

In Uganda, urban areas can often experience outbreaks of vaccine-preventable disease because inequities in access to vaccination can lead to poor immunisation coverage. The Infectious Diseases Research Collaboration (IDRC) evaluated the drivers of urban immunisation between June and December 2019 to determine the effectiveness of the Uganda National Expanded Program on Immunisation (UNEPI) service delivery model in Kampala city, the drivers of immunisation coverage, and the extent to which the UNEPI is adapting to these drivers. The scope of this report, which reflects phase 1 of the evaluation, is on demand-side issues.

The evaluation employed a parallel convergence mixed methods design. The researchers conducted secondary data analysis, document reviews and partner mapping, key informant interviews (KIIs), focus group discussions (FGDs), and in-depth interviews (IDIs). They carried out fact-checking interviews at national and global levels to validate findings. Study participants included EPI focal persons and health workers at different levels and community members. In addition, a household survey to quantify the drivers of the coverage in Kampala city was conducted among 590 caregivers of children aged 12-23 months.

The findings show that 41% of the surveyed children were fully immunised (lowest among children of caregivers of low socioeconomic status but uniformly distributed between formal and informal settlements), 57.6% were partially immunised, 26.5% were immunised on time, and the overall diptheria, pertussis, and tetanus (DPT1-DPT3) dropout rate was 17.3%. These findings indicate sub-optimal effectiveness of the EPI model for immunisation service delivery.

The facilitators and barriers of immunisation coverage in Kampala City are presented according to the evaluation's conceptual framework:

• Approachability and ability to perceive: Caregivers cited understanding the benefits of immunisation as the primary reason they chose to fully vaccinate their children. Conversely, inadequate information on the benefits of immunisation was the primary reason other caregivers did not fully vaccinate their children. This was due to the lack of an active programme to provide sufficient information about the need for immunisation through social mobilisation or routine service delivery. As a result, there is fear and mistrust of the vaccines, which is aggravated by negative influence from significant others and media. On the latter point, the majority of the respondents (n=354, 66.9%) in the household survey said they got information about immunisation from the media (TV, radio, and newspapers). The findings reveal vaccine hesitancy and refusal among some community members after hearing about and reading negative messaging regarding immunisation. These included vaccines being fake, new vaccines under trial only in Africa, and adverse events following immunisation (AEFIs).
• Acceptability and ability to seek: Refugees reported marginalisation when it came to accessing immunisation services: being skipped in queues, being left out during mass immunisation campaigns, and encountering rude health workers. They also felt left out of communications on immunisation, as the mainstream media mostly used local languages when announcing immunisation services. In addition, gender dynamics in the household limited some mothers' ability to seek immunisation services for their children due to pressure from their husbands not to vaccinate.
• Availability, accommodation, and the ability to reach: For example, caregivers reported frequent delays in the commencement of immunisation, delays as health workers waited for a requisite number of children before opening the multiple dose vaccine vials, and their own competing time demands.
• Affordability and ability to pay: Hidden costs that deterred caregivers included payment for immunisation cards, payment for the immunisation service, transport costs, and costs associated with meeting special requirements at immunisation points.
• Appropriateness and ability to engage: Lack of a follow-up system for immunisation makes it difficult to identify and trace defaulters due to the migrant nature of the population in Kampala City.

The report also examines adaptations that the Ministry of Health (MoH) and Kampala Capital City Authority (KCCA) have put in place in an effort to respond to the urban challenges of the EPI, including engagement of the private sector in immunisation services delivery as a way of increasing access to immunisation services and minimising delays at public health facilities. However, there are remaining weaknesses and challenges of the EPI model of immunisation service delivery in Kampala city, including:

• Limited engagement of religious and cultural leaders in awareness-raising efforts to reduce negative social influence (e.g., by spouses) that exacerbate fear and mistrust of vaccines;
• Limited use of social media by MOH/UNEPI to counteract immunisation-related misconceptions, misinformation, and conflicting/negative messages on social media;
• Inadequate mentorship and support supervision from KCCA, as well as high staff turnover of health workers in private health facilities, which create knowledge gaps on immunisation;
• Frequent vaccine stockouts attributed to an inadequate vaccine distribution system;
• Lack of a follow-up system for immunisation, which makes difficult to identify and follow up defaulters;
• Reliance on traditional social mobilisation structures (such as through engagement of political and local council leaders, health workers at facility level, and village health teams (VHTs) at community level) and limited efforts to engage non-health actors (e.g., boda-boda associations) in social mobilisation, which excludes some closed communities such as Eritreans, Indians, and Karamojong that require targeted approaches; and
• Inadequate and delayed facilitation (e.g., delayed receipt of allowances) for VHTs for immunisation activities, resulting in lack of motivation on the part of VHTs to conduct community mobilisation.

Based on the findings, the evaluators offer a series of recommendations. In the short term:

1. The MoH/UNEPI should develop a long-term urban immunisation strategy that prioritises urban-specific programming for immunisation services in Kampala city and other urban centres.
2. There is need to design a deliberate communication strategy on routine immunisation that highlights the benefits of immunisation, addresses misconceptions, and provides information on the current immunisation schedule.
3. The MoH/UNEPI should develop a social mobilisation strategy that addresses the complexity of an urban setting. The strategy should consider:
   • Using various channels to reach different sub-populations through existing associations (e.g., boda boda and taxi associations; market vendors);
   • Customising information, education, and communication (IEC) materials to reach different populations, and deliberately engaging closed communities (e.g., Indians, Ethiopians, and Eritreans) in immunisation through their leadership structures; and
   • Making a deliberate effort to continuously sensitise the public about immunisation on social media platforms.
4. The MoH/KCCA should work to engage the large private sector to strengthen immunisation and other health services in Kampala and other urban settings, such as by improving the sector's standards and coordination.
5. the MoH/UNEPI should consider deliberate investment in the distribution chain for vaccines and supplies in Kampala.
6. The MoH/UNEPI should adequately support health facilities to offer free immunisation services and provide refresher training to foster client-centred care.

In the longer term, the evaluators encourage the MoH/UNEPI to consider use of electronic registries for immunisation in urban settings and to investigate why some divisions of Kampala city are performing better than others in the same environment.

Lessons learned related to evaluation itself include: Given the complexity of Kampala city (e.g., the diverse ethnic groups), it is difficult to access and conduct interviews. Multiple levels of clearance and involvement of community leaders are key to successful data collection. Relatedly, continuous engagement of key stakeholders during design and implementation of evaluation ensures that the findings are relevant and timely.

Phase 2 of the evaluation will follow up on key findings from phase 1, evaluate the supply side drivers of immunisation coverage, and assess the UNEPI's ability to adapt to the challenges of immunisation in an urban context - particularly in the context of COVID-19. As of this writing, there are plans to develop urban immunisation guidelines that will eventually contribute to the Ministry of Health's urban health strategy. There are also plans to develop the urban health communication guidelines and implementation plan. The findings of phases 1 and 2 will inform the urban health plans.