Authors: Ghangha Jamin G. MPH, Sangwe Clovis N. MD, MSc, MPH, PhD(c), Njedock Nelson S. MD, Internist, Michael Budzi, MD, MPH.

Immunization is the most cost-effective measure of disease prevention. In addition to offering protection from preventable diseases, immunization also brings children and families into contact with the healthcare system, providing an avenue for delivering other basic health services and laying the foundation for primary healthcare. Optimal childhood immunization coverage has persistently remained a major challenge in Sub-Saharan Africa, especially in countries experiencing socioeconomic crises, civil wars, floods, and hard-to-reach enclaved communities

Cameroon has been experiencing insecurity and crisis events in the Far North, South West and North West regions of the country. A sociopolitical crisis hit the South West region in October 2016, affecting childhood immunization service delivery in the region. As a result, there was a drop-in immunization coverage from 2016 to 2019 for three key antigens; BCG, DPT3, and MR by 29%, 42%, and 33% respectively2. Parental (caregiver) barriers to childhood immunization to a certain extent can also be attributed to the significant decline observed in vaccination coverage in this region.

The challenges of childhood immunization can be broadly classified as health system barriers, healthcare provider barriers, access barriers, and parental (caregiver) barriers3.

Parental(caregiver) barriers to childhood immunization refer to factors or obstacles that prevent or hinder parents from ensuring their children receive recommended vaccines3. In most communities in the South West region of Cameroon, the woman is usually responsible for following up on children’s health. It is only in very rare cases where follow-up is done by the men who are typically involved in activities geared towards family livelihood and subsistence. Field experience has demonstrated that parents’ perception influences the vaccination of their children, and some of these perceptions have resulted in hindrances to the uptake of immunization in rural communities in this region. We recount the most frequently encountered parental (caregiver) barriers to childhood immunization identified during our field activities.

Gleaning from Rural Doctor’s experience and personal experience, we share some parental/caregiver barriers to immunization from our expertise in some remote areas in the Southwest region.

  1. Poor caregiver immunization knowledge

In enclaved rural communities of the South West region, the literacy rate is generally low, and this disparity is more pronounced among women 4. Although, women in this region are generally responsible for the well-being of their children, they do not understand the importance of vaccination for their children. Insufficient access to information on childhood vaccination further contributes to the higher number of unvaccinated children in these areas

2. Misconceptions about childhood immunization

Following interaction with parents in some rural communities, there is a prevailing perception that vaccines provide less effective immunity than experiencing the actual disease. Hence, they prefer to brave out the condition than immunization. In addition, the efficacy of traditional health practices is highly regarded and given a special place in health care as a substitute for vaccination. Parents (Caregivers) are as well accustomed to the reassurances given to them by traditional healers.

  1. Lack of trust in vaccines

This is a major reported barrier by most caregivers in rural communities. Caregivers vaccinate their children based on the belief that vaccines sent to them may be intentionally made harmful, low-grade, or expired. A nursing mother in Yoke, one of the villages in the Muyuka Health District, once told one of our field agents during a community health education visit, “I do not trust the vaccines they come to give our children. There is a plan to reduce our population and kill our children and that is why I cannot allow my child to take the vaccine”. Some caregivers have the perception that vaccines can cause physical disability or even death.

  1. Inconvenient immunization schedules

Most women in these rural communities are solely farmers and sometimes immunization days for their children are scheduled on farming days. This leaves them with the tough choice between immunization and feeding their families, with most caregivers eventually focusing on what the family will eat overtaking the child to the health facility for vaccination. The situation becomes even worse during harvesting periods.

  1. A negative service experience

Negative health service experiences also constitute a barrier to childhood immunization in these communities. The experience of negative encounters after a long preparation and a distant journey makes caregivers reluctant to return to the health facility to complete their child’s vaccination.

Mother Leticia, who had to balance her petit business and follow up on her child’s vaccination calendar, made it to the health facility after missing several routine visits for her one-year-old son; she had an uncomfortable encounter with a health worker and shared: “The nurse shouted at me for not taking the child for vaccination regularly, and this made  me not to go back to  that health center the following month.”

  1. Family size

In most rural and enclaved settings, we have worked in, family sizes range from 5 to 7 children5. This has affected immunization uptake in one way or another considering the burden of other children at home who also need care and attention.

Suggested measures to reduce parental barriers to childhood immunization in the South West region include but are not limited to the following;

  • Community health education by Community health workers (CHWs)     on the importance of routine immunization to children.
  • Implementing an effective communication strategy to demystify myths about vaccination in rural communities is an important step in curbing parental barriers in this setting. For instance, communities could be informed of the initiation progress and outcomes of vaccine trials prior to their marketing, local and international media sources.
  • The importance of community engagement in improving vaccination coverage cannot be overemphasized. To effectively plan immunization schedules, the local activities of the caregivers and the timing should be highly considered.
  • Integrating vaccination with other health packages could reduce vaccination anxiety and facilitate acceptance.

Conclusion: Knowing that routine childhood immunization is a lifesaving, cost-effective public health intervention, addressing challenges associated with the health system, provider and access barriers, and parental/care barriers is of utmost necessity. To reach Gavi’s 5.0 strategic goal of “leaving no one behind with immunization”, reaching these children is a global priority. Listening to and amplifying the voices of parents and caregivers as well as creating an enabling atmosphere for exchange between parents and health workers, will help us collectively find new pathways to primary health care for the future.

References

  1. Ozawa S. Return On Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011–20, HEALTH AFFAIRS 35, NO. 2 (2016): 199–207
  2. Saidu, Y., Vouking, M., Njoh, A.A. et al. The effect of the ongoing civil strife on key immunization outcomes in the North West and South West regions of Cameroon. Confl Health 15, 8 (2021). https://doi.org/10.1186/s13031-021-00341-0
  3. Bangura. Barriers to childhood immunization in sub-Saharan Africa: A systematic review, (2020) 20:1108. https://doi.org/10.1186/s12889-020-09169-4
  4. Dube, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., & Bettinger, J. A. (2013). Vaccine hesitancy: an overview. Human vaccines & immunotherapeutics, 9(8), 1763-1773.
  5. Nkuoh, G. N. (2009). Low uptake of contraceptives in rural areas in Cameroon: an examination of women’s attitudes. Rural and remote health, 9(3),1150