The last stretch: Barriers to and facilitators of full immunization among children in Nepal's Makwanpur District, results from a qualitative study.

BACKGROUND: Approximately 35% of Nepal's children have not received all recommended vaccines, and barriers to immunization exist on both the demand- (i.e., access, affordability, acceptance) and supply- (i.e., logistics, infrastructure) sides. OBJECTIVE: This article describes a formative study to understand the barriers to and facilitators of immunization in Makwanpur, Nepal from both the demand- and supply-sides. METHODS: Through in-depth interviews, key informant interviews, and focus group discussions (N = 76), we assessed knowledge, attitudes, and experiences with immunization; social norms related to immunization; perceptions of local health facilities; and descriptions of client-provider relationships. Data were analyzed using an iterative, grounded theory approach. RESULTS: Three major themes emerged, including positive demand of vaccines, lack of mutual trust between service seekers and service providers, and internal and external motivators of vaccine supply. On the demand-side, caregivers reported high levels of immunization-related awareness, knowledge, and acceptance, largely perceived to be due to a generational shift. On the supply-side, providers expressed passion for their work despite lack of support from local authorities and a desire for more training. Between caregivers and providers, lack of mutual trust emerged as a prominent barrier, revealing a cycle of positive service bias. CONCLUSIONS: We identified mutual trust as a key pathway toward reaching full immunization coverage in Nepal and we recommend future interventions adopt an approach which focuses on removing social barriers (i.e., distrust) and structural barriers (i.e., opening hours, neglected infrastructure) to immunization.

Rejoice architecture meets social norms to accelerate vaccination in Nepal: Protocol for a mixed-method quasi-experimental study.

Background: Each year, 600,000 children under 5 years old die from vaccine-preventable diseases globally. Immunization is an effective way to prevent many diseases, saving two to three million lives per year. The Nepal National Government recommends vaccinations for all children for 11 diseases by 15 months of age. However, only 78% of children between 1-2 years of age have received all recommended vaccines and only 43% receive them at the age-appropriate times for which they are scheduled. Objectives: This protocol describes the development of an intervention - called "Rejoice Architecture" - that is informed by three theoretical perspectives: choice architecture, the broken windows theory, and the theory of normative social behavior. We also describe a mixed-methods approach to develop the intervention, which will improve the physical and social environments of health facilities in Makwanpur, Nepal. We hypothesize this intervention will improve immunization behaviors and intentions among mothers of children younger than 2 years, pregnant women, and prospective mothers. Methods: We describe the qualitative formative assessment to understand existing attitudes, norms, and behaviors among caregivers, healthcare workers, and government representatives. The formative assessment will include in-depth interviews, key informant interviews, and focus group discussions. We also describe the overall quasi-experimental study design, used to assess intervention impact. Impact: This study will contribute to the social and behavioral change communication intervention research by offering a novel strategy for increasing immunization. This study will also illustrate to policymakers the value of structural change for health service delivery.