In Uganda, routine childhood immunization is generally high – but at the apex of the COVID-19 pandemic, access to vaccines and other important health care services was severely disrupted, exposing many to life-threatening illness.
The Uganda Ministry of Health and UN Expanded Program on Immunization (UNEPI), in collaboration with ICAP at Columbia University and the U.S. Centers for Disease Control and Prevention (CDC), conducted a study examining the social, behavioral, and access-related issues that influence demand and uptake of vaccines in Uganda, as well as factors affecting routine immunization amid the COVID-19 pandemic.
Surveying randomly selected caregivers, and interviewing key informants, namely, district health managers and health care workers in Kampala and Wakiso, the study revealed that before the pandemic, routine childhood vaccination against common diseases was as high as 94 percent. However, among those who could access a vaccination site during the pandemic, 24 percent noted that it took longer than usual to receive a vaccine and 10 percent reported they had to go home without vaccination because of vaccine stock-out. Survey participants expressed that limited access to transportation, concerns about contracting COVID-19, and lack of funds for transportation were the primary reasons for not acquiring routine immunizations at all during the pandemic.
Survey participants highlighted that the pandemic took a major toll on their livelihoods generally, leading to such outcomes as loss of employment, reduced salary, and limited food availability.
“During the COVID-19 lockdowns, it [COVID] was prioritized over other diseases,” a survey participant noted. “There were less health care workers for other services like routine immunization and some children missed vaccines.”
“It’s extremely important to understand how a pandemic or other public health emergencies can impact health care service delivery,” said Mansoor Farahani, senior technical advisor for ICAP’s Strategic Information unit and principal investigator of the study. “This knowledge helps us design interventions that mitigate barriers for similar situations in the future. Every community has different needs, so it’s crucial that these interventions are targeted. The findings of this study indicate that transportation, for example, is a major obstacle to accessing health care services during the lockdown.”
Among individuals who reported difficulties in accessing COVID-19 vaccines specifically, long waiting times, lack of awareness of vaccination sites and long distances to those sites, and concerns about vaccine side effects, were major barriers. Those who didn’t want to get a COVID-19 vaccine at all noted that lack of trust in the vaccine and fear of side effects informed their decision.
The survey revealed that television, radio, and health care providers were the most trusted sources for COVID-19 vaccination information in these two districts, but that sources of negative information or rumors about COVID-19 vaccines were friends, family, and social media. 90 percent of respondents, in fact, had heard negative information or rumors about the COVID-19 vaccine.
Overall, 82 percent of respondents indicated that they would be most likely to follow COVID-19 vaccine information from health workers, emphasizing the immense importance of health care leaders in vaccine communication and uptake in Uganda.
“It [COVID vaccine] reduces infection rates in the community because, as you see, when I leave here, I go back home to my family,” said a midwife working at Kawempe Hospital in Kampala. “Also, people in the community keep asking us health workers if we have been vaccinated such that they can also come and be vaccinated. They see us as role models.”
Given the survey findings, ICAP, in consultation with UNEPI, developed a series of recommendations delivered at a national dissemination meeting in April 2022. Since trust in health care workers was high, it was recommended that continued messaging via health care workers about vaccine safety and effectiveness would be an effective strategy for improving COVID-19 vaccination uptake. Continued training of health care workers for communicating and answering vaccine-related questions, and countering any prevalent rumors, would be critical to strengthening service delivery at COVID-19 vaccination sites.
“This data shows us that a great deal of progress has been made over the years in terms of increased interest in immunizations in Uganda,” said Dr. Henry G. Mwebesa, Director General of Health Services, Ministry of Health, “but this progress can only be sustained if robust structures are in place that won’t threaten it. It’s important that we now take this evidence and knowledge about obstacles communities face in accessing services and use it to improve our health systems. We want to ensure that there is not a high price impeding any person from living a long, a healthy life.”
While uptake of routine childhood immunizations has now increased after lockdowns have lifted, additional efforts are required for those still unable or unwilling to access essential health services. Concerns about child exposure to COVID-19 at health facilities and during transportation were critical factors from a caregiver’s perspective, so measures such as masking for all eligible children and adults should be implemented to protect infants who cannot mask in public transportation vehicles. Generally, addressing hurdles to transportation access could significantly improve routine childhood immunization uptake, especially during lockdown scenarios.
As a follow-on to the Uganda survey, ICAP is launching a study in Uganda to better understand how community outreach programs may increase routine vaccination uptake. ICAP also recently completed data collection for a study in Ethiopia assessing the social, behavioral, and access-related issues that influence demand and uptake of vaccines, including COVID-19 vaccines.
“This Uganda study has important implications not only for Uganda, but other countries in sub-Saharan Africa,” said Dr. Sam Biraro, ICAP country director in Uganda. “It shows us that consistent messaging through trusted sources can make a difference in increasing COVID-19 vaccine uptake, which could help get us all one step closer to better-protected, healthier communities.”
A major global health organization that has been improving public health in countries around the world for nearly two decades, ICAP works to transform the health of populations through innovation, science, and global collaboration. Based at Columbia Mailman School of Public Health, ICAP has projects in more than 30 countries, working side-by-side with ministries of health and local governmental, non-governmental, academic, and community partners to confront some of the world’s greatest health challenges. Through evidence-informed programs, meaningful research, tailored technical assistance, effective training and education programs, and rigorous surveillance to measure and evaluate the impact of public health interventions, ICAP aims to realize a global vision of healthy people, empowered communities, and thriving societies. Online at icap.columbia.edu