INTRODUCTION:

The benefits of vaccination are clearly demonstrated by the eradication or enormous decline of the many vaccine-preventable diseases incidences, but the coverage of the vital and highly recommended vaccines remains frequently inadequate causes suffering of children from diseases that would are prevented.

Immunization does prevent deaths and for last 3-4 decades it played a pivotal role in tackling infectious disease throughout the globe. Vaccines are one of the most successful and cost effective health interventions under specific protection of primary level of prevention. The benefits of vaccination are clearly demonstrated by the eradication or enormous decline within the incidence of the many vaccine-preventable diseases, but the coverage of the many highly recommended vaccines is still frequently inadequate and children remain suffer from diseases that would are prevented. The problem is paradoxically significantly more evident in children at risk of infectious disease-related complications, but can also be found in otherwise healthy children, at least in the case of some vaccines¹. India spends over Rs. 2.6 billion per year in immunization programmes for immunizing children against vaccine preventable diseases, including polio eradication. From where it’s huge success is self evident. Even though percentages of children aged 12-23 months, who are fully immunized is steadily increased from 43.5% in 2005-06 to 62.0% in 2015-16². The remaining gap is alarming. Despite the availability of safe and effective vaccines, the coverage of immunization against the main vaccine preventable diseases is still variables across different regions of India. Communication and social mobilization strategies always were major component in changing behavior of community and change in community’s vaccine acceptance, which help in preventing disease by improving immunization coverage. 3 Social determinants have the potential to affect immunization programs round the world with globalization and simple communication facilitating their effects.

Although India may be a leading producer and exporter of vaccines, the country is home to at least one third of the world’s unimmunized children. Fewer than 44 percent of India’s young children receive the complete schedule of immunizations. India’s vaccine deficit has several causes: little investment by the govt, and low demand due to a poorly educated population and therefore the presence of anti-vaccine advocates. Although the current immunization program targets twenty-seven million infants and pregnant women every year and is one of the largest immunization programs in the world, immunization rates through the national program are uneven across all states in India. The proportion of youngsters under age five who are vaccinated exceeds 70percent in just eleven states; it drops below 53 percent in eight states that also are the most populous.³ one of the key challenges is that children are still being missed from the immunization coverage. A number of studies have investigated the barriers to immunization in an attempt to understand why some vaccine-preventable diseases are still relatively common, even in countries with modern and highly efficient national health systems. Numerous studies have investigated immunization coverage, vaccine wastage and other aspects and have recommended strategies for increasing it^1,2,4,5,6,7. However, few studies have focused on managerial barriers for better and effective management of immunization clinics. The main aim of this paper is to discuss the recognized barriers to the vaccination of children confronting national health systems, providers and parents, and the ways in which they can be overcome. Therefore this study is necessary to address this lacuna and suggests solutions to address broad issues of strengthening the institutional framework, processes, evidence base and framework required for vaccine security, program management and regulatory issues to expand vaccine coverage.

METHODOLOGY:

Research Method and Design:

A qualitative research method was utilized which focused on the meaning, understanding and practices of professional health persons regarding the implementation of EPI in their context. An exploratory descriptive and contextual research design was used to explore and describe child attendants’ knowledge and practices of immunization. This approach assisted the researchers to understand the knowledge and practices in the implementation of EPI. The explorative part of the study was achieved by asking one key question of the participant, which was followed by probing questions regarding undefined areas. The explorative part of the study was achieved by giving participants the opportunity to describe their knowledge and practices about child immunization. Study site: This study was conducted at the following Immunization clinic and community health centers that were purposively selected on the basis of the total number of patients seen: Immunization clinic in JA Group of hospital, Rural Community Health Center Barai, and Hastinapur, sub health center Panihar and urban community health center Thatipur of district Gwalior Madhya Pradesh. Population and sampling: The population comprised by 34 professional health workers including ANM; MPW who were related with immunization and 150 beneficiaries’ attendants those attended for immunization for their children at those specific health centers were willing to participate in the study was included. Non-probability purposive sampling was used to select these immunization clinic and health centers. Non-probability purposive sampling was used to include professional health workers in the semi-structured interviews until data saturation was reached. The researchers included only those professional health workers who had worked two years and more in these health centers on the basis that they had thorough knowledge of the issues studied. The availability of the health workers and beneficiaries attendants during the data collection period was considered at immunization clinic and health centers. Data collection: The researchers used semi-structured interviews, and participants were asked one central question which was followed by set questions on a guide to further probe the issues studied. The central question which was asked of all participants was ‘Can you kindly explain how immunization is implemented in this clinic?’ The participants were given more time to clarify areas that were not clear to the researchers. Probing questions followed after each first response to the central question, so that researchers could clarify areas that were not clear. Field notes were written to capture non-verbal cues.

RESULTS AND DISCUSSION:

Table 1 summarizes the health system/health provider and logistic barriers that can influence vaccine administration. Vaccines with stringent storage requirements and maintenance of cold chains are challenge and cost increased remains a substantial barrier to immunization. However, some of the most obvious barriers are factors affecting the supply and distribution of vaccines concerned mainly in peripheral areas. Vaccines are not always sufficient and a significantly higher than expected number of children at high risk of infection do not receive adequate immunization. Similarly Shankar Prinja et al⁸ reported that the main reasons for delayed immunization were staff shortages, non adherence to plans and vaccine being out of stock and found that among the demand side factors, birthplace of the child and religion of the household heads came out as significant predictors while from the supply side availability of male health workers and equipment at the subcentres were the important determinants for month specific coverage. Our study also observed findings similar to Garcia et al⁹ where six groups of immunization barriers were identified; 1. Factors related to caregivers (24.4%), 2. Vaccinators (19.7%), 3. Health Centers (18.0%), 4. The Health system (13.4%), 5. Concern about adverse events (13.1%) and 6. Cultural and religious beliefs (11.4%); where groups 1, 5 and 6 together represented almost half (48.9%) of users indicating problems related to the demand for vaccines as the primary barriers to immunization. The possible reasons for this include mismatches in vaccine supply and inventory management, and the challenges felt by healthcare providers to order the available vaccine products and incorporate them into clinical practice. Lack of knowledge of its indications and contraindications among health workers is a long-standing problem. Providers may find it difficult to keep abreast of current immunization schedules and guidelines. In our study clearly showed that about 35% of these providers considered measles is a potentially serious disease for younger children and that they knew very little about the characteristics of measles vaccines and the recommendations for their use. Providers also reported a lower vested interest in immunizations than clinical staff. These discrepancies in reported immunization practices between providers and staff may be a barrier to full immunization⁶.

Poor communication with parents is due to inadequate knowledge of the advantages of vaccinations among healthcare workers can have substantial negative effects on vaccination coverage. Primary-care providers play a supportive role in educating patients and parents on the safety and effectiveness of the vaccines recommended by health authorities, and can positively influence the rates of immunization just by answering parents’ questions and addressing common misconceptions. A number of studies have clearly shown that parents consider healthcare workers to be the most important source of information when deciding whether their child should be given a vaccine^10,11. It is well known that dissatisfaction with the information given by doctors is one of the most frequently reported reasons for low vaccine acceptance rates¹² , As healthcare workers’ knowledge of vaccines is one of the most critical points conditioning vaccine acceptance by parents, health functionaries will have take up the Health education aspects of the mothers more enthusiastically through personal Interpersonal communication and Focal group discussion in different set ups e.g., clinics, community group meetings or wherever the mother could be met either singly or in groups and incorporate vaccine information in the curriculam. This would remove their different confusion and improve their confidence about the programme and that would help in reaching the target of the vaccine coverage of the children¹³

Missed opportunities (MOs) for administering vaccines or recalling the need for their administration are other barriers to fulfilling immunization requirements in a timely fashion. Overall, the children with a recorded MO were 3.1 times more likely to be incompletely immunized than those with no recorded MO (95% CI 1.87–5.14), and this likelihood increased to up to nine times in the case of the children with a higher percentage of visits that represented MOs. The importance of reducing MOs seems to be particularly important in the case of children throughout the world^14,15. It has been suggested that health care centers (i.e. healthcare settings that offer continuous, comprehensive and accessible primary care) are optimally suited to provide immunization to children¹⁶ but, where such facilities are not available, the integration of healthcare sites by means of automatic reports of immunizations received in complementary settings is important. Schools can also be used to increase children immunization by introducing specific educational programmes concerning the importance of vaccines, verifying immunization records and strongly encouraging the parents and teachers to undergo needed vaccinations^16,17 Reasons for missed opportunities were found as Lack of simultaneous administration, Unaware child (or adult) needs additional vaccines, Invalid contraindications, Inappropriate clinic strategy. For avoiding MO more sensitivity towards mothers and community perceptions and knowledge is needed to create higher levels of social demands for immunization and a better understanding of woman autonomy is required, which implies an analysis of all interwoven conditions determining her mobility, her control over resource and her power to make decisions within the family. Poor quality, lack of timeliness and attitude of staff affect mothers’ demand and usage of service. A lack of adequate information from vaccine providers regarding the vaccination status of every child to whom they ought to administer the recommended vaccines can significantly influence vaccination coverage, and it has been shown that the use of computerized, population-based systems that collect and consolidate vaccination data is essential to this end¹⁸. These systems not only support clinical deciding and supply vaccination coverage reports, but they will also help in vaccine inventory management and have the power to get RR messages. Unfortunately, such systems aren't fully developed or really effective in our country and, in some cases, providers themselves negatively interfere with their use. The most frequently described were the human and financial resources associated with implementing an RR (Reminder/Recall) system communicating to an Individual/beneficiary, or a attendant, that the Individual is due now or on a future date (reminder) or past due (recall) for one or more recommended immunizations. Reminder/Recall can be initiated by many different parties: a Provider for its Patients, a health plan for its enrollee, and a lack of confidence in the accuracy of patient immunization records thanks to inadequate communication among multiple immunization providers. Other barriers were changes in staff workflows, the absence of appropriate electronic patient-tracking facilities and uncertainties concerning the success of such a system. Finally, it was noted that the effectiveness of an RR system designed to improve vaccination in at-risk children can vary depending on the intimacy between the healthcare workers managing the system and the patients or their families. In India Indeed, less than half of the respondents (45.78%) could identify all the mandatory vaccines for infants. Of even greater concern is that only in between 30-40% knew that pertussis, measles, mumps, Rota virus and rubella were diseases that are vaccine-preventable in children. Moreover, the mothers' lack of knowledge about vaccinations is supported by the finding that the main reason for not vaccinating or not completing the vaccination schedule was that they had not been advised about them. The level of knowledge about mandatory vaccinations for infants correlated significantly with the mother's level of education and socio-economic status. Low education level of parents may be associated with nonadherence to vaccination programmes, and illiterate parents may be overrepresented among the no responders.¹⁹ Providers should explain all of the benefits and risks of vaccines in detail, acknowledging parental concerns and respectfully trying to correct any misconceptions. People perceive risks differently, and then the way during which possible risks are communicated is critical. Baron²⁰found that people opposed to vaccination could be persuaded to vaccinate if they placed themselves in the child’s position and then asked themselves whether they preferred a greater or lesser chance of death, and whether it mattered if the outcome occurred as a result of someone’s act or omission. In resource poor settings like India, decisions to use the vaccine are expected to be guided by the cost associated with its introduction. While the concerns regarding the costs are legitimate, recent data suggest that the cost of the vaccine has reduced substantially²¹.
Table 2 summarizes parental barriers to vaccination and possible means of overcoming them. Confusing vaccination schedules, costs, religious objections, frequent childhood illnesses leading to delayed immunization, difficulties in remembering an appointment (Missed Opportunities/Delayed vaccination) and transportation problems are frequent reasons given by parents to explain why their children were not vaccinated at the appropriate time or not at all²². However, most of the negative parental attitudes are due to a lack of knowledge of the clinical relevance of many vaccine-preventable diseases and the very good safety and tolerability of all of today’s marketed vaccines, this were also stated by Yawn22. Study based on FAQs by inquisitive mothers revealed that majority of mothers was ignorant about the vaccine roles and importance. This ignorance might be due to their less scope of going outside and so many questions raised by the mothers were not only associated with immunization as well as with other problems of the children²³.Some parents believe that the immunity evoked by vaccines is less effective than that due to natural disease, and they prefer to face the risks of illness rather than those of immunization. This was clearly shown by Prislin et al.²⁴ who found that, together with safety concerns, beliefs in natural immunity were the main contributors to parents’ negative attitudes to vaccinations It was noted in the previous study that Two-thirds of the inquisitive mothers (66.54%) that mothers asked questions on immunization schedule/next visit, contraindications of immunization, adverse reactions following immunization, treatment/care of the reaction after immunization, vaccine during fever and illness, feeding after vaccination, other vaccines than schedule, These are the mothers who would require more interpersonal communication as some socio-economic problems led them to remain outside the ideal childbearing age²³. There are several loopholes in the mother’s knowledge regarding immunization. Many of them had no knowledge about compulsory vaccines. The knowledge regarding Pentavalent, BCG, and Measles vaccine was 57.2%, 50.4%, and 46.0% respectively. Only 34.4% and 33.6% knew about Hib vaccine and DPT respectively and 23.2% were aware of recently launched ROTA virus vaccine¹⁹.Various studies in recent past has revealed that implementation of immunization services under UIP are not up to satisfactory standards and still more efforts are needed for improving the quality of services for the successful achievement of expected targets.²⁴ Despite inadequate knowledge and attitude of mothers towards infant immunization, (42.4%) mothers had good change and 32.3% were seeking to know about practice of infant immunization and individual vaccine. A study carried out by us during MR vaccine campaign suggested that hesitant attendants/mothers underestimate the potential severity of the measles and rubella disease and have significant doubts over the safety and efficacy of the MR vaccine when compared to their non hesitant counterparts²¹. These misconceptions are likely to influence the way parents balance risk and benefit in making a decision about vaccination. So, by its nature, risk perception is innately subjective and decisions not carried by parents according to experts or health professionals. Currently, there's a scarcity of effective evidence-based intervention for approaching vaccine hesitancy. More sensitivity towards mothers and community perceptions and knowledge is needed to create higher levels of social demands for immunization. A better understanding of woman autonomy is required, which implies an analysis of all interwoven conditions determining her mobility, her control over resource and her power to make decisions within the family. It would even be important to succeed in the ring of influence around families that refuse vaccination. Influencing the bonding, bridging, and linking capital will help to reach, persuade, and negotiate with the influencers around the resistant individual²¹.

Table1. Barriers to vaccination and solutions identified at Health System/Organization level

Barriers	Solutions
Vaccine Shortage/Difficult vaccine storage/Logistic problems to reach clinics	Improved vaccine infrastructure Fair reimbursement for vaccines Vaccine inventory maintained improve vaccine infrastructure and logistic management Better understanding required
Supply and Distribution	Vaccine inventory management/Improve vaccine infrastructure and logistic management
lack of knowledge of its indications and contraindications	Educational programmes/Evidence based Information about the effects and side effects of vaccines and vaccination
Conflict	Better Ergonomics Conflict Resolution and management Improved Quality management system
Missed opportunities/Delayed vaccination	Integration of healthcare sites Educational programmes / Immunization registries
Economic problems	Implementation of efficient and effective recommendations to minimize the problem Economic help/Incentives provision
Poor communications with parents / Poor access to children’s immunization records	Educational programmes/Immunization registries

Table2. Main Parental/Beneficiary barriers to immunization and possible solutions

Parental barrier	Solutions
Poor understanding of the real value of vaccines/Knowledge deficit	Education Programs/Community outreach
Fear of adverse events	Educational programmes; adequate information from physicians
Problems in understanding the complexvaccination schedule	Recognized sources of information / Evidence based guidelines about the effects and side effects of vaccines and vaccination
Problems in understanding the complexvaccination schedule
Economic problems	Economic help/Vaccines free of charge Technical development training and workshop organized
Economic problems
Lack of a system to collect and consolidate vaccination status of single individuals/beneficiaries	Computerized immunization registries; activation of reminder/recall systems; establishment of a immunization platform with an age-based recommendation; vaccination requirements for child care
Missed opportunities/Missed vaccination	Use of reminder and recall (RR) systems/Information through schools/

CONCLUSION:

Evaluation is an important and integral component of all system as without evaluation we will not know the success or failure. It is only through evaluation one can know the important impact i.e. achievement against the set objectives. What were the problems faced, what were the changes and modifications with reasons there of?²⁵. As most of the problems that lead to low vaccination coverage in children depend on the lack of knowledge of vaccines of healthcare providers and parents, educational programmes should be specifically aimed at each of these groups. Moreover, the design and development of new vaccines and the alternative routes of administration should represent a possible solution for overcoming barriers to immunization. It is also essential that all physicians providing immunization develop approaches that acknowledge parental concerns and respectfully try to correct any misconceptions. The risk of non-acceptance can be further reduced by implementing systems for recording vaccine administration and sending out reminders, providing immunization services in special medical homes or by integrating healthcare sites1 Immunization management is complex and context specific, varying across time, place, and vaccines. Obstacles in immunization occurs along a continuum between full acceptance and outright refusal of all vaccines, i.e., when there is acceptance of some and delay or refusal of some of the recommended vaccines. It is influenced by factors like complacency, convenience, and confidence. Parents had concerns relating to the risks of vaccination and expressed a lack of trust in health authorities.⁷

To conclude there is need to provide more information on childhood immunization, targeting mothers of all ages and service providers and school teacher; promote immunization benefits, emphasizing complete the immunization schedule; encourage more parents to attend immunization clinics, where they can access correct information about childhood immunization. The study further recommends the necessity to emphasize women’s economic status to enable them afford costs related to accessing immunization services, improve male involvement in childhood immunization by creating an information package targeting men of all ages; establish rural maternal and child health centres to reach communities that are from health facilities with primary health care services including immunization and information.

REFERENCES:

1. Esposito S, Principi N, Cornaglia G; ESCMID Vaccine Study Group (EVASG). Barriers to the vaccination of children and adolescents and possible solutions. Clin Microbiol Infect. 2014 May;20 Suppl 5:25-31. doi: 10.1111/1469-0691.12447. Epub 2014 Jan 24. PMID: 24354949. [Available on https://pubmed.ncbi.nlm.nih.gov/24354949/ and last access on 28th Oct 2020]

2. United Nations International Children Emergency Fund; Vaccine management Assessment field Assessment and Observation from National Stores and five selected states of India. New York 2010. Availavle on http//www.unicef.org/india/ vaccinewastage_Assessment_india.pdf

3. National Family Health Survey 2015-16 (NFHS-4) Madhya Pradesh State Fact sheet 2015-2016. Available from: http://rchiips.org/nfhs/nfhs4.shtml.

4. Tao W, Petzold M, Forsberg BC. Routine vaccination coverage in low and middle-income countries: further arguments for accelerating support to child vaccination services. Glob Health Action 2013; 6:1 –8.

5. Debaje SP. Communication and mobilization campaigns for immunization (CMCI): Need of time for strengthening immunization services in India. Int J Res Med Sci 2014; 2: 830-3.

6. Prislin R, Sawyer MH, Nader PR, Goerlitz M, De Guire M, Ho S. Provider-staff discrepancies in reported immunization knowledge and practices. Prev Med 2002; 34: 554–561.

7. Agarwal AK, Sengar A, Gupta P, Gupta R. A Study of Vaccine Hesitancy among Mother and Care Provider during MR Vaccine Campaign. Natl J Community Med 2019;10(11): 605-611

8. Shankar Prinja, Madhu Gupta, Amarjeet Singh and Rajesh Kumar. Effectiveness of planning and management interventions for improving age-appropriate immunization in rural India. Bulletin WHO 2010;88: 97-103. DOI:10.241/BLT.08.059543.

9. Garcia L et al. Understanding the main barriers to immunization in Colombia to better tailor communication strategies. BMC Public Health 2014 14: 669.

10. Heininger U. An internet-based survey on parental attitudes towards immunization. Vaccine 2006; 24: 6351 –6355.

11. Burnett RJ, Larson HJ, Moloi MH et al. Addressing public questioning and concerns about vaccination in South Africa: a guide for healthcare workers. Vaccine 2012; 30(Suppl 3): C72–C78.

12. Casiday R, Cresswell T, Wilson D, Panter-Brick C. A survey of UK parental attitudes to the MMR vaccine and trust in medical authority. Vaccine 2006; 24: 177–184.

13. Anil Kumar Agarwal, Piyush Datt Swami*, Shatkratu Dwivedi. A study to assess the effectiveness of short training session on immunization knowledge of mothers attending immunization clinic. International Journal of Community Medicine and Public Health | May 201 8 | Vol 5 | Issue 5 Page 1 DOI. http://dx.doi.org/1 0.18203/2394-6040.ijcmph20180001]

14. Esposito S, Pelucchi C, Tel F et al. Factors conditioning effectiveness of a reminder/recall system to improve influenza vaccination in asthmatic children. Vaccine 2009; 27: 633–635.

15. Cecinati V, Esposito S, Scicchitano B et al. Effectiveness of recall systems for improving influenza vaccination coverage in children with oncohematological malignancies. Hum Vaccin 2010; 6: 194–197.

16. Szilagyi PG, Rand CM, McLaurin J et al.; Working Group on Adolescent Vaccination in the Medical Home. Delivering adolescent vaccinations in the medical home: a new era? Pediatrics 2008; 121(Suppl 1): S15–S24.

17. Lindley MC, Boyer-Chu L, Fishbein DB et al.; Working Group on the Role of Schools in Delivery of Adolescent Vaccinations. The role of schools in strengthening delivery of new adolescent vaccinations. Pediatrics 2008; 121(Suppl 1): S46–S54.

18. Kelly JS, Zimmerman LA, Reed K, Enger KS. Immunization information systems national research and evaluation agenda. J Public Health Manag Pract 2007; 13: 35–38.

19. Zuzak TJ, Zuzak-Siegrist I, Rist L, Staubli G, Simoes-W€ust AP. Attitudes towards vaccination: users of complementary and alternative medicine versus non-users. Swiss Med Wkly 2008; 138(47–48): 713–718. Baron J. The effect of normative beliefs on anticipated emotions. J Pers Soc Psychol 1992; 63: 320–330.

20. Anil Kumar Agarwal, Aditi Sengar, Preeti Gupta, Ramniwas Mahore. ‘MR Vaccine Campaign in India’ – Get ahead Success. South Asian Res J Med Sci; Vol-1, Iss- 2 (Aug-Sep, 2019): 51 -55

21. Yawn BP, Xia Z, Edmonson L, Jacobson RM, Jacobsen SJ. Barriers to immunization in a relatively affluent community. J Am Board Fam Pract 2000;

22. AK Agarwal, RN Mahore. A Study on FAQs of the mothers attending an immunization clinic in G. R. Medical College, Gwalior”. I. Journal of Preventive and Social Medicine.Vol 44 (3-4) July-Sep 2013. [ISSN 0301-1216, Index Medicus].

23. Prislin R, Dyer JA, Blakely CH, Johnson CD. Immunization status and sociodemographic characteristics: the mediating role of beliefs, attitudes, and perceived control. Am J Public Health 1998; 88: 1821 – 1826.

24. Burman NR. Functioning of anganwadi centers under ICDS scheme: An evaluative study, Assam Agriculture Univ., Faculty of Home Science, Department of child development and family relations, 2001.]

25. Ashok K Agarwal, Anil K Agarwal, Anju Agarwal. Role of Management of Information System in Health Care. Asian J. Management 3(4): Oct.-Dec.2012, pp 238-242]

Received on 05.11.2020 Modified on 20.12.2020

Asian Journal of Management. 2021; 12(3):265-270.

DOI: 10.52711/2321-5763.2021.00040