Study to Describe Barriers to Childhood Vaccination in Mozambique

A number of barriers to higher and more timely vaccination coverage have been identified,including vaccine stock ruptures; lack of fixed facilities within easy access of approximately half of the population; shortage of well-trained field staff; and misconceptions regarding vaccination by primary care givers and families. Much of the Mozambican population does not speak Portuguese, and 70 percent of women country-wide are illiterate, compounding the challenge of public education. A number of these factors are the legacy of decades of war, during which health facilities and schools were destroyed, trained staff were lost, and few new professionals were trained.

An international country case study on communication support for immunization (UNICEF, WHO/AFRO, and USAID 1999) recommended formativeresearch on barriers to and motivations for improving immunization performance.USAID funded the Ministery of Health (MOH) through Project CHANGE, to conduct such a study during2002/3. This report presents study results.

The MOH's educational arm, RESP, is responsible for information and education insupport of vaccination. To date, there have been various successes concerning specific vaccination campaigns, but limited educational activities to support routine vaccination. Most efforts involve group health education talks at the point of service. A basic understanding of routine vaccination is missing, which may affect parents' demand forvaccination services; and adherence to the vaccination schedule.

One province was selected from each of the three regions of the country; including a worst-case scenario (Zambezia) and a best-case scenario (Gaza) in terms of vaccination coverage figures (range 23%-64%).

The study gathered quantitative and qualitative information about problems, barriers, and successes in relation to vaccination services in 36 communities. The results are intended to be used to develop clear recommendations for policies, management, and activities of the MOH's Expanded Program on Immunization, and, ultimately, to increase vaccination coverage countrywide.

The study explores:

• perceptions, experiences and expectations among the population sampled concerning the provision of vaccination services in fixed posts and mobile brigades
• the problems of access to vaccination services in terms of time and quality of services
• health worker role in provision of vaccination services in fixed posts and mobile brigades
• sources of information used by the population regarding vaccinations
• the occurrence of missed opportunities for vaccination and reasons for missed opportunities
• perceptions, understanding, and use of the child health card by primary caregivers and health workers

Of the three sampled provinces, Gaza showed better results for almost all indicators. The percent of on-schedule children who use fixed services is significantly higher than in the central and northern provinces (73 percent versus 41 percent in Zambezia and 43 percent in Nampula). The reasons are clear: Gaza has a much lower population (just above 800,000 compared to a population that exceeds 2,000,000 in both Zambezia and Nampula9), and a higher resource base due to greater proximity to Maputo City. The population is more literate, better educated, and has greater access to information. The logistics of training, consumables and supplies, and supervision also tend to be easier in the southern provinces. Government and non-governmental support generally decreases with distance from the country's capital. According to the Health Facilities Survey (USAID/EHP 2000) Gaza supports an average of 8842 people per health facility; versus 14,200 in Nampula and 13,838 in Zambezia.

The report proposes that with appropriate inputs similar increases in coverage could be expected in all regions in the three intervention areas discussed above. Conclusions include the following:

Access to Services

The largest increase in vaccination coverage will come with expanded access to services. To reach children that are currently out of range of both fixed and mobile vaccination services, expansion of services is essential.

Quality of Services

It can be assumed that the 8-13 percent of mothers who drop-out of the vaccination process have access to services; but stopped using them for some reason likely related to service provision. Therefore, with increased quality and consistency of services, this portion of users can be retained and ultimate coverage further increased.

Information/Education/Communications

Given that demand is already high, interventions seeking to increase coverage through educating on the value of vaccinations will result in small increases in full coverage. However, interventions designed to increase knowledge and understanding of the vaccination calendar are more likely to result in increases in timely vaccinations and thus reduce the period that a child is at risk of vaccine preventable diseases.

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