Research examples

CHAPTER ONE

INTRODUCTION

1.0. Overview

This chapter introduces the topic, the background of the study, the definition of immunisation and vaccinations, the concept of routine immunisation as a program policy instrument for improving child health services, and the context in which the proposed study would take place. It further stated the thematic area of focus in the study, the problem statement and outlines the goal, objectives, study questions, scope, significance of the study and concluded with a chapter summary.

1.1            . Background of the Study

Immunization is the process of reinforcing an individual’s immune system with an immunogen in order to develop immunity and protect the individual from harmful germs. It can be active, in which an external agent is administered to promote immune responses, or passive, in which immunity is conferred through an indirect method, such as breastfeeding. Vaccines are substances that are used to promote antibody formation and offer protection against one or more diseases. They are made from the causative agent of a disease, its products, or a synthetic equivalent that has been processed to behave as an antigen without generating the disease (Oxford English Dictionary). Vaccines have become vital in disease prevention since their development by Edward Jenner in 1796, and they have shown cost effectiveness in lowering the cost of medical treatment and increasing the likelihood of child survival before the age of five (Shukla & Shah, 2018).

Globally, vaccination has helped save the lives of numerous children under the age of five. Over 2.3 million children receive protection from diseases that can be prevented in childhood each year (UNICEF, 2020). In order to increase vaccine coverage globally, the WHO established the Immunization Agenda in 2020, however the recent COVID-19 pandemic has a history(WHO, 2021). However, WHO has declared vaccine hesitancy as one of the ten threats affecting health coverage in 2019. This has been seen as the failure of more than 5 million children to receive their DTP dose on time has had a negative influence on the progress gained in vaccination coverage over the past nearly 30 years. The Essential Recovery Plan of the IA 2030 Plan outlines three essential action plans, including catching up, restoring, and strengthening efforts to enable recovery of the 40% loss suffered by the end of 2021 in achieving the immunization program target across nations (Immunization Agenda, 2021).

Uganda continues to provide routine immunization through UNICEF and other partners across the nation, with 90% and 86% of the targeted 1.34 million children receiving DTP 3rd dose and Measles containing vaccines, respectively, by the end of 2020. Vaccine hesitancy, a bottleneck to vaccine uptake caused by a variety of factors such as a lack of providers and parental knowledge, poor procedures and practices in health facilities, a lack of immunization policy and programs, and political issues, has had a negative impact on childhood immunization in Sub-Saharan Africa and Uganda in general (Abor et al., 2022; Cooper et al., 2021; Feletto & Sharkey, 2019). This increases the probability of children failing to meet projected developmental milestones, resulting in poor cognitive development, poor school performance, and low or negative economic growth for the country (Cooper et al., 2021).

The healthcare system, and more specifically the immunization and vaccination program, still lacks the necessary technology to help monitor and administer vaccines to children more effectively. For instance, only around 6/10 of the applications that are available to enhance routine immunization coverage were found to assist mothers and caregivers in reminding them about dates, schedules, and the recording of crucial information to enable greater access and coverage of immunizations (Abahussin & Albarrak, 2016).

1.1.1    Physiology of vaccines and immunisations

Immunisation is the process of vaccine inoculation into a person to provide protection against disease causing organisms. There are two types of immunisations. Active immunization is one in which body is exposed to a pre-treated antigen in order to stimulate immune responses.

Normally, the antigen (vaccine) is picked up by T-cells, which deliver it to B-cells, and the B-cells produce antibodies against such antigen, registering a long-term memory of 5, 10, or more years. The most popular routine vaccinations used in paediatrics active immunization, for example, are made of attenuated whole cell or inactivated germ cells. Passive immunization occurs when an antibody created outside of the body is injected to induce antibody formation in the body without informing the T and B cells. The total protection is merely temporary. Vaccination is the process of administering a vaccine to an individual via any means or pathways in order to elicit an immune response and create protection against a disease or antigens. Vaccines are biological agents that are used to stimulate an individual’s immune response and protect them. This vaccine is either derived from pathogenic material or synthesized from other proteins with similar biological components as disease-causing microorganisms. In nature, vaccines can be live or attenuated. Live vaccines have the ability to proliferate, particularly in immunocompromised individuals, whereas inactivated whole or part cells may not.

The table below shows the various types of vaccines so far developed since vaccine discovery in 1876 and are in use for providing protection against disease causing pathogens in the general population.

Table 1.1. Vaccine types licensed and in use since 1789, (Pollard & Bijker, 2021).

1.1.2    The p-factors influencing vaccine uptakes among mothers and caregivers

While adherence is the willingness to accept and compliance is the ability to accept vaccines or any medical care, the acceptance and rejection of vaccines, also called vaccine hesitancy, among mothers and caregivers around the world has been noted, studied, and documented in a number of literary works. These have been through the concept of 3Cs: conspiracy, complacency, and convenience; however, thematic factors such as providers and parents, procedures and practices, policy and programs, and political factors are theme groups into which these components can be categorized, as discussed below.

1.1.3    Providers and parental factors influencing vaccine uptakes

As defined by Chapter 59 of the Ugandan Children Act 1997, providers and parents play critical roles in ensuring childhood development and growth. However, there is considerable regional variation in completion of routine vaccines schedule in Uganda with only 48.6% national completion rate and the notable decline in some region especially due to providers’ knowledge of vaccines, mothers’ lack of awareness of the benefits of vaccines, education of mothers and caregivers, providers’ attitudes toward parents and vice

1.1.4    Procedure and practice factors influencing vaccine uptakes

Parents and caregivers of children always have preconceived notions and beliefs about health workers, health facilities, and the health system as a whole. Because of this, most parents recognize that certain processes and practices maybe subpar when witnessing their children being vaccinated, which calls into doubt the vaccinators’ procedures and practices.

1.1.5    Policy and program factors influencing vaccine uptakes

The WHA-2020 endorsed the Immunisation Agenda 2030 with the goal of restoration of vaccine uptake, providing catch-up strategies for immunisation, and strengthening the overall national and global approaches to vaccines uptake.  However, inadequate policy and program implementations such as traditional approach to immunizations (static), hidden vaccination cost, weak policies on facility operating hours, lack of cross-sector collaboration, poor social inclusion program policies, and lack of awareness on Children’s rights to access health services have jeopardized WHA-2020 progress.

1.1.6    Political factors influencing vaccine uptakes

The Convention on the Rights of the Child in was ratified in 1997 and subsequent approval of SDG 3.2 to reduce newborn and child mortality by 2030 in Ugandan Parliament was seen as the gateway to ensuring sustainable health care for citizens. Nonetheless, the nation is still having difficulty achieving the 2016 Uganda Integrated Early Childhood Development Policy’s goal of overall child health. The nation’s growing political upheaval has frequently led to insecurity, instability, and a lack of support for programs designed especially for rural counties. This shows that inadequate roads may compromise parents’ safety and ease of access when they bring their children for vaccinations.

1.1.7    Pager Cell Division, Kitgum Municipal, Kitgum Municipal

Pager Cell Division in Kitgum Municipality, Uganda, has 11 Divisions/Cells, 43 villages, and a population of 226,857. Despite 35 health facilities, the district faces issues like poor urban services, overpopulation, unemployment, poor waste management, and urban poverty. The doctor-to-population ratio is 1: 1,542, and the district has coverage of BCG, DPT, and Measles at 82.0, 83.4, and 69.5%, respectively.

1.2            . Problem Statement

For nearly 30 years, in 2021, global immunization coverage experienced its worst relapse in history, with more than 5 million (40%) children missing zero-dose DPT (Immunization Agenda, 2030). The global coverage for DTP vaccines fell from 86% to 83% in 2020, accounting for over 95% of dropouts, and MCV1 fell from 86% to 84% all attributable to the recent pandemic, a weak healthcare system, under-resourced facilities, societal challenges and a general lack of funds(Muhoza et al., 2021).

In Uganda vaccine coverage and adherence remains low only 55%(Bakibinga et al., 2020). Despite the fact that vaccinations save $44 for every $1 invested on a child, only 90% and 86% of Uganda’s targeted 1.34 million children received the pentavalent and MR vaccines by 2020, an achievement which is below 95% of the global target. The same year, children under-fives saw a 9% decrease in overall DTP and vitamin A coverage(UNICEF Uganda Annual Report 2020). Previous studies on factors affecting EPI utilisation have been based on the 3Cs- Conspiracy, Convenience, and Complacency concept citing factors such as level of mothers and caregivers’ education, clinic operating hours, vaccine availability, extended family structures, choice of opportunity cost (private marginal vs. social marginal benefits), and maternal knowledge of immunization schedules, however, thematic approach as proposed in the current study have not been examined.

The researcher proposes to analyse vaccines adherence and compliance among mothers and caregivers from a thematic point of; 1) providers and parents, 2) procedures and practice, 3) policy and programs, and 4) political factors at Pager Cell Division, Kitgum Municipal between January and December 2021 and provide a deeper understanding of the thematic elements impacting mothers and caregivers uptake of immunisation services and as well draw a recommendations to strengthen child health services in the region and nationally.

1.3            Research Objectives

This section has outlined the general objectives and specific objectives that guide the overall study

1.3.1    General Objective

The primary goal of this study is to analyse adherence and compliance to routine immunisation services among 323 mothers and caregivers of children aged 0-18 months at Pager Cell Division, Kitgum Municipal, Northern Uganda, between January and December 2021.

1.3.2    Specific Objectives

Specifically, the study will:

1. Determine the provider and parent factors influencing immunization adherence and compliance among mothers and caregivers of children aged 0-18 months.
2. Find out how procedures and practices in the health facility affect immunization adherence and compliance rates in children aged 0-18 months.