Barriers to Childhood Immunisation and Local Strategies in Four Districts in South Africa: A Qualitative Study

"The recommendations have been crafted in a manner to help facilitate effective and locally acceptable approaches to address the barriers not only in the study districts but also in other districts or communities facing similar challenges with the uptake of childhood immunisation services."

In South Africa, 62% of children in 2020 were deemed as multidimensionally poor and suffering from various deprivations. In such settings, vaccine-preventable illnesses remain a danger. South Africa comprises diverse settings where the reasons for zero-dose and under-immunised children vary significantly and are often intertwined with local contexts. The study described in this paper identifies supply and demand barriers and proposes context-specific, community-focused strategies to improve childhood immunisation in four districts in South Africa with a high percentage of children who have not received the first dose of the diphtheria tetanus-pertussis-containing vaccine.

This study used a mixed-method approach. In each of the four districts, 15 in-depth key informant interviews with health workers and local health managers and four focus group discussions (10 participants per focus group discussion) with community members and caregivers were held over a three-month period. 

Results by district, in brief:
 

• In eThekwini Metropolitan Municipality, immunisation services face some challenges and barriers, but they are supported by two facilitators of immunisation - namely, parental beliefs and gender equality. The four major barriers include interaction with healthcare workers, experience of care at healthcare facilities, accessibility of healthcare services, and family dynamics (see Table 4 in the paper).
• In the City of Johannesburg Metropolitan Municipality, district immunisation services are supported by one facilitator of immunisation - namely, gender equality. The three major barriers reported include interaction with healthcare workers, experience of care at healthcare facilities, and family dynamics (see Table 5).
• In Oliver Tambo District, immunisation services face six major barriers: religious beliefs, traditional health practices, interaction with healthcare workers, experience of care at healthcare facilities, accessibility of healthcare services, and family dynamics (see Table 6).
• In Dr Kenneth Kaunda's District, immunisation services face six major barriers affecting the demand and uptake of immunisation services: religious beliefs, traditional health practices, interaction with healthcare workers, experience of care at healthcare facilities, accessibility of healthcare services, and family dynamics (see Table 7).

Table 8 provides an overview of the facilitators, major barriers, and minor barriers per district.

Despite the varying role of factors affecting demand and uptake of immunisation services, three consistent findings stand out as major barriers across all districts:
 

1. Interaction with healthcare staff: This finding highlights that beyond the medical aspects of healthcare, the patient's interaction between patients and staff plays a key role in shaping perceptions and behaviours related to immunisation services. Addressing these factors is crucial for ensuring equitable access to immunisation and improving public health outcomes across diverse communities.
2. The overall experience of care at healthcare facilities: Negative experiences, such as long wait times, stock shortages, or inadequate communication, can deter community members from accessing immunisation services. By improving the overall experience of care, healthcare workers can improve satisfaction, and ultimately, immunisation uptake.
3. Family dynamics: For example, the issue of teenage pregnancy coupled with the practice of parents leaving their children with their grandmothers in order to seek employment creates logistical challenges for accessing immunisation services, as the grandparents may prioritise childcare responsibilities over healthcare appointments. Such a scenario highlights the important role family dynamics play in shaping individuals' decisions regarding immunisation uptake, as well as the impact it has on the ability of people to access health services. 
    

Table 9 details strategy recommendations to address each of the factors identified through the data analysis process. These recommendations have been crafted to help facilitate effective and locally acceptable approaches to address the barriers - not only in the study districts but also in other areas facing similar challenges with the uptake of childhood immunisation services. For example, peer support networks could be established to support: parents/young mothers in sharing experiences and information, grandparents in accessing educational materials, and grandparents in connecting with other caregivers in similar roles. By aligning each recommendation with corresponding demand side, service-delivery interface, or supply side components in the immunisation service process, this approach is intended to serve as a strategic tool for prioritising strategies, interventions, and allocating resources effectively.

In conclusion: "Addressing the barriers affecting the demand for and uptake of immunisation services requires sustained investment, innovation, and collaboration. The recommended strategies will assist districts in addressing these barriers. By prioritising childhood immunisation and implementing community-based strategies, we can ensure that every child has the opportunity to be protected from vaccine-preventable diseases."