Exploring the drivers of low DPT3 vaccination coverage and the implications in rural, urban and peri-urban Uganda: a cross-sectional study of Hoima and Wakiso districts of Uganda

In a recent observational study, we reported findings on barriers to effective immunization in rural Hoima District, western Uganda, where it emerged that rural contexts may not have same determinants as peri-urban or urban contexts driving underimmunization. In a continuation of that work to incorporate peri-urban and urban barriers to immunization, this study reports a follow up on the recommendations of our earlier publication, through a case study of (peri) urban Wakiso district, and incorporates and compares the findings from both districts to propose unified recommendations to address low immunization coverage (under 90%) in Uganda. The aim was therefore to determine and describe the barriers to the uptake and utilization of immunization services in Hoima and Wakiso districts of Uganda and propose interventions, strategies and approaches that can help address the problem of vaccine hesitancy and underimmunization in Uganda. This was a mixed methods study, that utilized interviews with child caregivers, for the quantitative design and focus group discussions (FGDs) with caregivers of children eligible for vaccination, and single in-person in-depth interviews with health workers, and immunization focal persons (KIs) for the qualitative part in both Wakiso (per-urban) and Hoima (rural) districts of Uganda. In this study, majority of the caregivers (369/643) were 21–25 years of age, female, married and protestants, with basic secondary education. The study found that 91% (588/643) of respondents consider vaccines safe, 85% (547/643) consider vaccines effective, 95% (611/643) have complete trust in vaccines and 13% have some misgivings regarding vaccines. Both Districts are under-immunized (Hoima 81% and Wakiso 75.3% DPT3 coverage). Factors independently associated with low DPT3 coverage include: low trust in vaccines, being a single parent caregiver, those who consider vaccines unsafe, relying on social media as source of vaccine information, those who did not receive any education on vaccines during immunization visits, and those who have misgivings about vaccines. Additional drivers of underimmunization include access difficulties, geographical barriers, inadequate funding, cold chain inadequacies, inadequate social mobilization, vaccine stock outs, high training needs for health workers, and adverse events following immunization. This study found that both Hoima and Wakiso districts are under-immunized given a DPT3 vaccine coverage less than 90%. The Ministry of Health needs to train Health Workers through improved mentorship, enhance outreach services, social mobilization, and build trust in communities.