Barriers to effective uptake and provision of immunization in a rural district in Uganda – ScienceOpen
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      Barriers to effective uptake and provision of immunization in a rural district in Uganda

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          Abstract

          Introduction

          Hoima, one of the largest districts in mid- western Uganda, has persistently performed poorly with low immunization coverage, high immunization drop outs rates and repeated outbreaks of vaccine preventable diseases especially measles. The objectives of this study were to evaluate the state of immunization services and to identify the gaps in immunization health systems that contribute to low uptake and completion of immunization schedules in Hoima District.

          Methods

          This was a cross sectional mixed methods study, utilizing both qualitative and quantitative approaches. A situation analysis of the immunization services was carried out using in-depth interviews with vaccinators, focus group discussions and key informant interviews with ethno-videography. Secondary data was sourced from records at headquarters and vaccination centres within Hoima District. The quantitative component utilized cluster random sampling with sample size estimated using the World Health Organization’s 30 cluster sampling technique.

          Results

          A total of 311 caretaker/child pairs were included in the study. Immunization completion among children of age at least 12 months was 95% for BCG, 96% for OPV0, 93% for DPT1, 84.5% for DPT2, 81% for DPT3 and 65.5% for measles vaccines. Access to immunization centres is difficult due to poor road terrain, which affects effectiveness of outreach program, support supervision, mentorship and timely delivery of immunization program support supplies especially refrigerator gas and vaccines. Some facilities are under-equipped to effectively support the program. Adverse Events Following Immunization (AEFI) identification, reporting and management is poorly understood.

          Conclusion

          Immunization services in Hoima District require urgent improvement in the following areas: vaccine supply, expanding service delivery points, more health workers, transport and tailored mechanisms to ensure adequate communication between health workers and caretakers.

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          Most cited references12

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          Inequities among the very poor: health care for children in rural southern Tanzania.

          Few studies have been done to assess socioeconomic inequities in health in African countries. We sought evidence of inequities in health care by sex and socioeconomic status for young children living in a poor rural area of southern Tanzania. In a baseline household survey in Tanzania early in the implementation phase of integrated management of childhood illness (IMCI), we included cluster samples of 2006 children younger than 5 years in four rural districts. Questions focused on the extent to which carers' knowledge of illness, care-seeking outside the home, and care in health facilities were consistent with IMCI guidelines and messages. We used principal components analysis to develop a relative index of household socioeconomic status, with weighted scores of information on income sources, education of the household head, and household assets. 1026 (52%) of 1968 children reported having been ill in the 2 weeks before the survey. Carers of 415 (41%) of 1014 of these children had sought care first from an appropriate provider. 71 (26%) carers from families in the wealthiest quintile knew > or =2 danger signs compared with 48 (20%) of those from the poorest (p=0.03 for linear trend across quintiles) and wealthier families were more likely to bring their sick children to a health facility (p=0.02). Their children were more likely than poorer children to have received antimalarials, and antibiotics for pneumonia (p=0.0001 and 0.0048, respectively). Care-seeking behaviour is worse in poorer than in relatively rich families, even within a rural society that might easily be assumed to be uniformly poor.
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            WHO and UNICEF estimates of national infant immunization coverage: methods and processes.

            WHO and the United Nations Children's Fund (UNICEF) annually review data on immunization coverage to estimate national coverage with routine service delivery of the following vaccines: bacille Calmette-Guérin; diphtheria-tetanus-pertussis, first and third doses; either oral polio vaccine or inactivated polio vaccine, third dose of either; hepatitis B, third dose; Haemophilus influenzae type b, third dose; and a measles virus-containing vaccine, either for measles alone or in the form of a combination vaccine, one dose. The estimates are based on government reports submitted to WHO and UNICEF and are supplemented by survey results from the published and grey literature. Local experts, primarily national immunization system managers and WHO/UNICEF regional and national staff, are consulted for additional information on the performance of specific immunization systems. Estimates are derived through a country-by-country review of available data informed and constrained by a set of heuristics; no statistical or mathematical models are used. Draft estimates are made, sent to national authorities for review and comment and modified in light of their feedback. While the final estimates may not differ from reported data, they constitute an independent technical assessment by WHO and UNICEF of the performance of national immunization systems. These country-specific estimates, available from 1980 onward, are updated annually.
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              Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015.

              Global efforts have increased the accuracy and timeliness of estimates of under-5 mortality; however, these estimates fail to use all data available, do not use transparent and reproducible methods, do not distinguish predictions from measurements, and provide no indication of uncertainty around point estimates. We aimed to develop new reproducible methods and reanalyse existing data to elucidate detailed time trends. We merged available databases, added to them when possible, and then applied Loess regression to estimate past trends and forecast to 2015 for 172 countries. We developed uncertainty estimates based on different model specifications and estimated levels and trends in neonatal, post-neonatal, and childhood mortality. Global under-5 mortality has fallen from 110 (109-110) per 1000 in 1980 to 72 (70-74) per 1000 in 2005. Child deaths worldwide have decreased from 13.5 (13.4-13.6) million in 1980 to an estimated 9.7 (9.5-10.0) million in 2005. Global under-5 mortality is expected to decline by 27% from 1990 to 2015, substantially less than the target of Millennium Development Goal 4 (MDG4) of a 67% decrease. Several regions in Latin America, north Africa, the Middle East, Europe, and southeast Asia have had consistent annual rates of decline in excess of 4% over 35 years. Global progress on MDG4 is dominated by slow reductions in sub-Saharan Africa, which also has the slowest rates of decline in fertility. Globally, we are not doing a better job of reducing child mortality now than we were three decades ago. Further improvements in the quality and timeliness of child-mortality measurements should be possible by more fully using existing datasets and applying standard analytical strategies.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: SoftwareRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                14 February 2019
                2019
                : 14
                : 2
                : e0212270
                Affiliations
                [1 ] East Africa Centre for Vaccines and Immunization (ECAVI), Kampala, Uganda
                [2 ] Makerere University, Department of Paediatrics & Child Health, Kampala, Uganda
                [3 ] Egerton University, Department of Paediatrics & Child Health, Nakuru, Kenya
                [4 ] Mulago National Referral Hospital, Directorate of Paediatrics & Child Health, Kampala, Uganda
                [5 ] World Health Organization (WHO), Kampala, Uganda
                [6 ] Makerere University, Department of Nursing, Kampala, Uganda
                [7 ] Sefako Makgatho Health Sciences University, Pretoria, South Africa
                University of Sydney, AUSTRALIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-1840-7402
                http://orcid.org/0000-0002-1312-6804
                Article
                PONE-D-18-14838
                10.1371/journal.pone.0212270
                6375600
                30763355
                f163b0de-a998-439e-b0a3-378ed8b6e7a9
                © 2019 Malande et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 17 May 2018
                : 30 January 2019
                Page count
                Figures: 1, Tables: 3, Pages: 15
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100004423, World Health Organization;
                Award Recipient :
                This study was funded fully by the CDC Small Grants 2017"- Uganda - Research grants for supporting immunization through the WHO country office - Uganda to OOM.
                Categories
                Research Article
                Medicine and Health Sciences
                Infectious Diseases
                Infectious Disease Control
                Vaccines
                Biology and Life Sciences
                Immunology
                Vaccination and Immunization
                Medicine and Health Sciences
                Immunology
                Vaccination and Immunization
                Medicine and Health Sciences
                Public and Occupational Health
                Preventive Medicine
                Vaccination and Immunization
                People and Places
                Geographical Locations
                Africa
                Uganda
                Medicine and Health Sciences
                Pediatrics
                Child Health
                Medicine and Health Sciences
                Public and Occupational Health
                Child Health
                Medicine and Health Sciences
                Infectious Diseases
                Viral Diseases
                Measles
                Medicine and Health Sciences
                Health Care
                Communication in Health Care
                Biology and Life Sciences
                Immunology
                Immune Response
                Medicine and Health Sciences
                Immunology
                Immune Response
                Social Sciences
                Anthropology
                Cultural Anthropology
                Religion
                Social Sciences
                Sociology
                Religion
                Custom metadata
                All relevant data are within the paper. However, any additional data or information can be made fully available, without restriction upon formal request to the authors, or to the East Africa Centre for Vaccines and Immunization, 2 sports lane, Naguru, 3040, Kampala, website/url: http://www.e-cavi.com/. If any aspects of data access require prior permission, then approval can be obtained from the School of Medicine, Research and Ethics Committee (SOMREC), Makerere University College of Health Sciences, and the Uganda National Council of Science and Technology (UNCST), reference: SOMREC IRB (REC REF 2017-077), UNCST (SS4245).

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