Coverage and Drivers to Reaching the Last Child With Vaccination in Urban Settings: A Mixed-Methods Study in Kampala, Uganda.

BACKGROUND: Limited evidence exists regarding the drivers of vaccination coverage and equity in Kampala city, despite frequent measles outbreaks, inequities in vaccination coverage, and the decline in vaccination coverage rates. This study was designed to determine vaccine coverage among children aged 12-36 months and to understand its demand-side drivers. METHODS: We utilized a mixed-methods parallel convergent study design. A household survey was conducted to quantify the drivers of vaccine coverage among households with children aged 12-36 months. We employed a multistage sampling approach to select households, using a primary sampling unit of an enumeration area. We conducted 30 key informant interviews, 7 focus group discussions, and 6 in-depth interviews with representatives from the immunization program, health workers, and parents residing in areas with low vaccine coverage. RESULTS: Of the 590 enrolled children, 340 (57.6%) were partially vaccinated, 244 (41.4%) were fully vaccinated and had received all the recommended vaccinations, and 6 (1.0%) had never received any vaccine. Of the 244 with all recommended vaccinations, only 65 (26.6%) received their vaccines on time. Access to vaccination services was high (first dose of diphtheria, pertussis, and tetanus [DPT1] coverage of 96%), but utilization decreased over time, as shown by a dropout rate of 17.3% from the first to third dose of DPT. The main driver of complete vaccination was the parents' appreciation of the benefits of vaccination. Among partially vaccinated children, the barriers to vaccination were inadequate information about vaccination (its benefits and schedule), vaccine stock-outs, long waiting times to receive vaccination services, and hidden vaccination costs. CONCLUSION: Vaccination needs to be targeted to all children irrespective of whether they reside in slum areas or nonslum areas, as most are under-vaccinated. Social mobilization and communication efforts should be tailored to the complexities of urban settings characterized by transient and diverse populations with different cultures.

Health worker perspectives on the possible use of intramuscular artesunate for the treatment of severe malaria at lower-level health facilities in settings with poor access to referral facilities in Nigeria: a qualitative study.

BACKGROUND: Innovative strategies are needed to reduce malaria mortality in high burden countries like Nigeria. Given that one of the important reasons for this high malaria mortality is delay in receiving effective treatment, improved access to such treatment is critical. Intramuscular artesunate could be used at lower-level facilities given its proven efficacy, ease of use and excellent safety profile. The objective of this study was therefore to explore health workers' perspectives on the possible use of intramuscular artesunate as definitive treatment for severe malaria at lower-level facilities, especially when access to referral facilities is challenging. The study was to provide insight as a formative step into the conduct of future experimental studies to ascertain the feasibility of the use of intramuscular artesunate for definitive treatment of severe malaria in lower level facilities where access to referral care is limited. METHODS: This qualitative study was done across three southern States in Nigeria (Oyo, Cross River and Enugu). Key informant interviews were conducted over a period of three months between October and December 2014 among 90 purposively selected health workers with different roles in malaria case management from primary care to policy level. A thematic content analysis was used to analyse data. RESULTS: Overall, most of health workers and other key informant groups thought that the use of intramuscular artesunate for definitive treatment of severe malaria at lower-level facilities was possible. They however reported human resource and infrastructure constraints as factors affecting the feasibility of intramuscular artesunate use as definitive treatment for severe malaria in lower-level facilities.. Specifically identified barriers included limited numbers of skilled health workers available to manage potential complications of severe malaria and poorly equipped facilities for supportive treatment. Intramuscular artesunate was considered easy to administer and the proximity of lower-level facilities to communities was deemed important in considering the possibility of its use at lower-level facilities. Health workers also emphasised the important role of operational research to provide additional evidence to guide the implementation of existing policy recommendations and inform future policy revisions. CONCLUSIONS: From the perspective of health workers, use of intramuscular artesunate for definitive treatment of severe malaria at lower-level health facilities in Nigeria is possible but dependent on availability of skilled workers, well-equipped lower-level facilities to provide supportive treatment There is need for further operational research to establish feasibility and guide the implementation of such an intervention.