Determinants of Immunisation Dropout among Children under the Age of 2 in Zambézia Province, Mozambique: A Community-Based Participatory Research Study Using Photovoice

"The community-based participatory research approach allowed community members to engage throughout the research stages, ensuring that the findings and resulting recommendations are community-centred."

In Namarroi and Gilé districts of Zambézia province, Mozambique, roughly 19% of children under the age of 2 start but do not complete the recommended vaccination schedule. Determinants of immunisation dropout have been shown to be highly contextual, including combinations of individual, interpersonal, and health systems factors. This study used a community-based participatory research (CBPR) approach, featuring Photovoice methods, that engaged caregivers of young children and health workers to identify key influences on under-2 immunisation dropout in Namarroi and Gilé districts.

CBPR engages community representatives throughout the research process in an attempt to reduce power imbalances between researchers and participants, create an environment in which participants feel comfortable discussing sensitive topics, and facilitate the co-creation of contextually sensitive and community-centred knowledge. Photovoice, a method through which people can share their stories using photographs that visually represent their experiences and perspectives, can empower participants to craft rich stories, generating data that might not be captured through standard interview techniques.

The Increasing Vaccination Model, developed by the World Health Organization (WHO) Behavioural and Social Drivers of Vaccination (BeSD) working group, guided data collection and analysis. The researchers adapted this model to incorporate elements of the UNICEF Caregiver Journey Model, dividing the "practical issues" category into three subcategories to capture the vaccination timespan (pre-service, during-service, and post-service).

Participants were identified through health facility vaccination records and included caregivers of children aged 25-34 months who were fully vaccinated (hereafter, "FV"; n=10) and partially vaccinated (hereafter, "PV"; n=22). The researchers also collected data from 12 health workers responsible for delivering immunisations at the selected health facilities. Four Mozambican caregivers (referred to as Caregiver Researchers) were recruited from the local communities, were trained in research ethics and qualitative methods, led data collection, and assisted with data analysis. The study was conducted between February 2020 and March 2021.

Caregiver Researchers provided cameras to caregiver participants, gave detailed instructions on their use, and asked caregivers to take photos related to their experiences immunising their child. Caregiver Researchers returned after 2-6 days and conducted audio-recorded, in-depth interviews that began with the caregiver explaining the meaning and importance of each of the 5 photos she felt represented the most meaningful depictions relating to her immunisation experience.

In addition, SMS (short messaging service) exchanges and semi-structured interviews were used to document health workers' perceptions of caregiver immunisation experiences, their beliefs about causes of dropout, and their experiences administering vaccines to children under 2. Each health worker was provided a phone with the Telegram application set up for group chats with the Caregiver Researchers and study team members. Over a 3-week period, health workers were asked to send photos and messages whenever they had an experience or observation related to under-2 immunisation.

The study highlighted the immense effort caregivers put into vaccinating their children and the numerous and difficult barriers they face, which arose in all categories of the Increasing Vaccination Model. In general, PV caregivers described abandoning vaccination after encountering multiple cross-domain barriers, rather than dropout being caused by a single barrier.

There were several notable differences between the most common subjects of PV and FV caregivers' photos. Sixty-four per cent of PV caregivers, versus only 30% of FV caregivers, selected at least one photo depicting them caring for their child who was experiencing side effects after the vaccination, and many voiced concerns about these side effects. Conversely, 60% of FV caregivers selected at least one photo of their own child or other children in the community who were healthy and growing well due to vaccines, a subject that only 27% of PV caregivers photographed. Roughly half of caregivers in both groups took photos of family and friends, but they described those photos differently: FV caregivers were much more likely to describe active support (e.g., family accompanying them to the health facility), while PV caregivers typically described only passive encouragement from family or talked about times when family members did not provide help with the vaccination process.

Four main patterns of barriers leading to dropout emerged:

1. Social norms and limited family support place the burden of vaccination on mothers: Limited family support was in part due to community beliefs that vaccination responsibility resides with mothers and that fathers should not be involved in the process. Both caregivers and health workers noted that reliable, consistent mobile brigades would help to address the practical barriers associated with travelling to health facilities, especially for those mothers who lack support from family members.
2. Perceived poor quality of health services reduces caregivers' trust in the health system: For example, PV caregivers described being frustrated by interactions with disengaged health workers. After expending significant effort to reach the health facility, some caregivers arrived to find that health workers were late or were busy talking on their phones, causing them to lose faith in the health system and lose motivation to vaccinate. Health workers described their own challenges in delivering vaccines and providing quality care to every child, including stockouts of vaccines and other supplies and high work burden due to insufficient human resources
3. Concern about side effects leads to hesitancy: This concern was also greater for PV caregivers who lived far away and felt that the long walk home aggravated the side effects. Health workers felt that caregivers might not be aware that reactions are relatively common and are rarely harmful in the long term, and they noted that better communication with caregivers is important for reducing dropouts caused by fear of side effects.
4. Power dynamics at the health facility make caregivers hesitant to seek and advocate for vaccination services: There were strong social norms around bathing the child before vaccination to avoid being rejected or humiliated, which was exacerbated by the public nature of the health facility, where immunisation activities and conversations take place in front of other caregivers due to lack of private rooms. A few PV mothers described instances when health workers sent them home without delivering any vaccinations. Even when PV caregivers believed that their children needed to be vaccinated, they were hesitant to approach the health workers to request the vaccine, fearing that they would be yelled at. From the health worker perspective, however, some of the missed opportunities for vaccination were due to challenges they faced regarding vaccine delivery and cold chain policies. The data suggest a breakdown in communication between health workers and caregivers that exacerbated perceptions of poor service quality.

COVID-19 created additional barriers related to social distancing, mask requirements, supply chain challenges, and disrupted outreach services.

Overall, the findings support the need for health systems strengthening to increase vaccination completion, including reinvestment in community-centred vaccine outreach services, improved supply chains, health facilities that allow for privacy and confidentiality, and a sufficient, motivated health workforce. Capacity building should support health workers to engage in respectful, empathic, and patient-centred communication. Involvement of community leaders, religious leaders, and community health workers in those communication strategies may improve vaccination uptake.

"To successfully implement these recommendations, there is a need for further research on the best channels of communication between health facilities and the communities they serve, as well as on how best to design and implement empathy-building trainings for health workers. Additionally, there is a need to better understand how to engage husbands and other family members in the vaccination process to reduce the burden on mothers."

In conclusion, this study demonstrates that "immunisation dropout is complex, with caregivers facing different combinations of barriers and facilitators over the course of their child's immunisation journey. The findings highlight the need for improved quality and reliability of vaccination services and for community-centred solutions that remove practical barriers and empower caregivers to complete the vaccination process."