Description
Introduction
There has been a rapid increase in the volume of internal migration in Nepal over the last 30 years, with the volume increasing from 15% in 2011 to 18.2% in 2022. Higher mobility poses barriers to continued care. The Nepal Demographic Health Survey 2022 reports a concerning increase in the percentage of children not receiving any vaccination, escalating from 1% in 2016 to 4% in 2022. In order to understand the routine vaccination status among these children, Kathmandu University, JSI, and UNICEF Nepal conducted a rapid assessment to explore the behavioral and social drivers influencing the low routine vaccine uptake among caregivers and health workers (HWs) including Female Community Health Volunteers (FCHVs) in Nepal.
Methodology
We conducted a qualitative study design using human-centered design and rapid inquiry to explore the drivers for low routine childhood vaccination among caregivers and HWs, including FCHVs. We used purposive sampling to select three provinces with low childhood vaccine uptake among underserved and marginalized communities and to enroll 54 caregivers of children under two (total 48 children) and 12 HWs. Interviews with caregivers and HWs were conducted using tools from the WHO Behavioral and Social Drivers of Vaccination guidance. The Journey to Health (JTH) and Immunization was used to analyze the findings.
Results and discussions
Among the total 48 children, 12 were under-immunized and three were zero dose. These children were primarily from low-income and migrant families (internal and external). The external migrants were from border country India, and the internal migrants were particularly the mobile population representing the geographical variation from the eastern part to the western part of Nepal. Caregivers faced barriers vaccinating their children due to limited awareness on the importance of vaccines, vaccine cards, and immunization sites and hours, fear of side effects, and religious beliefs; lack of decision making power of female caregivers; competing household, social, religious, and economic priorities; being turned away from immunization service; disrespectful behavior of health workers; and inadequate information on next visits and adverse events following immunization.
HWs and FCHVs faced challenges providing immunization services including limited knowledge about migrant populations in their communities and updated national immunization protocol; inadequate refresher training for FCHVs; time constraints; lack of human resources, distance between communities, not getting the required materials and supplies; and lack of and a fear of mistrust from the community.
Conclusions
The use of practical frameworks like the JTH can help identify social and behavioral drivers of vaccine uptake from caregiver and health worker perspectives. The study underscored substantial challenges in immunization, particularly the insufficient information and awareness among health workers and local bodies concerning migrants and their immunization status, leading to equity concerns. Tailored and targeted interventions and strategies should be designed specifically to these migrants and floating populations in order to reach the immunization targets and ensure that immunization service is accessed by all, contributing to universal health coverage.
Acknowledgment
Study participants, Research team, Behavior Science Center members, JSI and UNICEF Nepal.
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