Perceptions of Childhood Vaccination Practices among Beneficiaries and Healthcare Service Providers in Slums under the National Immunization Program of India: A Qualitative Study

"You cannot compare slums with any other settings. These settings are like hell. Thus, we need extraordinary planning and implementation to improve the mindset of the people and the healthcare delivery system in the slums." - healthcare service provider

The population density of Mumbai, India, is approximately 73,000 per square mile, and those who live in its slums are underprivileged - leading to vulnerability to various disease outbreaks. This qualitative community-based cross-sectional study documents the perceptions of caretakers, community members, and healthcare service providers related to childhood vaccination practices in slums under the national immunisation programme of India.

Forty focus group discussions (FGDs) with 370 stakeholders - caretakers, community members, and healthcare service providers - were carried out. The researchers identified themes based on the perspectives shared by beneficiaries and service providers in the FGDs, with selected findings as follows:

• Beneficiaries' perspectives: Poor awareness of vaccination is a major reason for its poor compliance. Most people had no idea about vaccine-preventable diseases (VPDs), though they were aware of the benefits of vaccination to a limited extent and were aware of the place, day, and time of vaccination sessions in their area. The majority of caretakers mentioned TV, radio, and newspaper as their main sources of vaccine-related information; healthcare workers were also considered a vital source. FGD participants felt that health staff should be polite and respectful, maintain cleanliness, provide drinking water, and deliver complete information related to vaccination. One mother said, "We all are busy in our work, if we could get reminders through phone calls or personal visits one day prior to our kids' vaccination then we will make it." Some participants had various concerns and fears around vaccination (e.g., fear of adverse events, loss of daily earnings). Some of their suggestions to improve vaccination services include:
  • Extended sessions - vaccination in evenings and on weekends;
  • Vaccination at the door, as in the pulse polio programme;
  • Reminders: SMS (text messages), personal visits, or community announcements;
  • Incentives and recognition for completing vaccination;
  • Awareness on vaccination using appropriate media (e.g., television, radio, newspaper); and
  • Parent-friendly healthcare delivery system.
• Service providers' perspectives: All agreed that VPDs are serious and considered vaccination to be one of the effective ways to prevent them. They said awareness among the slum community is low except for some diseases like polio, measles, and tetanus due to ongoing vaccination rounds under Mission Indradhanush. Awareness usually increases at the time of epidemics or outbreaks due to associated fears, but regular and effective communication with all potential stakeholders is warranted. They noted that the healthcare delivery system faces various supply- and demand-side challenges and proposed some solutions (e.g., active community participation to improve awareness and overall vaccination coverage, trust and corporate with the healthcare delivery system).

Thus, this study found that people generally had trust in the public health delivery system for vaccination services. However, they expected healthcare service providers to be polite, supportive, and friendly and were concerned about long waiting times and poor service arrangements such as lack of educational materials at the vaccination site. This study observed that a focus on modification of behaviour and attitude of healthcare service providers is warranted - e.g., "Healthcare service providers should be able to provide information to beneficiaries and communities through commonly agreed communication strategies."

In conclusion: "Initiatives such as regular interactions at different levels, effective communication including reminders, behavior interventions, the continued supply of vaccines and logistics, additional resources for the vaccination program, incentives and recognition, extended sessions and people-friendly healthcare delivery system could be helpful to strengthen the routine vaccination practices in slums."