Determinants of immunization dropout among children under the age of two in Zambézia Province, Mozambique: A community-based participatory research study using Photovoice.

Abstract

Introduction: Immunizations are highly impactful, cost-effective public health interventions. However, there remain significant gaps and inequities in complete vaccination coverage. In Zambézia Province, Mozambique, 37.9% of children under-2 years start but do not complete the basic vaccination schedule. We aimed to describe caregivers’ experiences with the immunization process and identify determinants of vaccine dropout in two districts in Zambézia. Methods: Following a community-based participatory research approach, we used Photovoice and semi-structured in-depth interviews (IDIs) to explore vaccination experiences for ten and 22 caregivers of children aged 25-34 months who were fully-vaccinated and partially-vaccinated, respectively. We also collected data from 12 health workers via SMS exchanges and IDIs. The Increasing Vaccination Model informed the analysis, which focused on describing facilitators and barriers to vaccination. Themes were generated through identifying patterns between vaccination determinants, comparing caregivers’ experiences, disaggregated by vaccination status. Health worker data added depth to the themes and illuminated where caregiver and health worker perspectives did and did not align. Results: Four main patterns of barriers leading to vaccination dropout emerged: 1) social norms and lack of family support place the immunization-seeking burden largely on mothers, 2) perceived poor quality of health services, including vaccine stockouts, reduces caregivers’ trust in health services, 3) concern about side-effects, exacerbated by vaccine “accumulation” when catch-up doses are needed, leads to vaccine hesitancy, and 4) caregivers feel hesitant to seek and advocate for vaccination due to power imbalances between them and health workers. Vaccination dropout occurred after encountering multiple barriers that simultaneously influenced the vaccination process. Caregivers who completed vaccination noted specific strategies, including accompaniment to the health facility by their husbands or assistance with caring for other children while they were gone, that enabled them to overcome barriers and complete vaccination. Conclusion: Barriers to immunization are multi-factorial and require strengthening health systems to overcome, including improving logistics to avert vaccine stockouts and building health worker capacity while emphasizing empathic communication with caregivers. Improving the reliability of routine immunization outreach services could address access challenges and improve immunization uptake, particularly for caregivers located far from health facilities and those who lack family support.