The urban-poor vaccination: Challenges and strategies in low-and-middle income countries

ABSTRACT

Vaccination is one of the success stories of public health. The benefit of vaccination goes beyond individual protection to include promoting population well-being, improving cognitive development, and increasing economic productivity. However, the existing inequalities in the access to vaccination undermines its impact. There are significant variations in the coverage of vaccination between and within countries. Despite that urban populations have better access to health services; evidence has shown that the urban poor have the worst health indicators including vaccination uptake. Additionally, there are unique challenges affecting vaccination in urban settings, especially in urban slums. This paper has discussed key challenges some of the proposed interventions that can improve urban vaccination service delivery.

KEYWORDS:

• Vaccination
• urban poor
• uptake
• strategies
• policy
• challenges
• inequalities

Introduction

Vaccination has had a significant impact on public health¹ and is considered one of the most cost-effective public health interventions and second in impact only to clean water.² Some of the successes of vaccination are the eradication of smallpox in 1980³ and the decline in the major threats against human health like polio, measles, and Haemophilus influenza type B, among others.¹ Eradication of smallpox led to the introduction of the Expanded program on Immunization (EPI) in 1974 by the World Health Organization (WHO).⁴

The Global Vaccine Action Plan 2011–2020 developed by the WHO estimated that every year vaccination averts approximately 2.5 million deaths from infectious diseases.⁵ In their modeling of the estimation of the health impact of vaccination against 10pathogens in the 98 low-income and middle-income countries (LMICs), Xiang Li et al reported that vaccination averted 37 million deaths between 2000 and 2019. The report further stated that vaccination will have prevented about 69 million deaths (95% confidence interval 52–88 million) between 2000 and 2030.⁶ Additionally, Doherty et al have also reported that vaccination does have positive impact on general health wellbeing, cognitive development as well as economic productivity.⁷

Therefore, it is crucial that people get vaccinated against various diseases to improve health outcomes. As such, the importance of equity in terms of access to vaccination cannot be overemphasized. Although the last decade has witnessed tremendous efforts in reaching children with vaccines, about 1.5 million children die every year from vaccine-preventable diseases.⁸ Globally, about 83% of infants got vaccinated with three doses of diphtheria, pertussis and tetanus (DPT) containing vaccine in 2020.⁹ However, according to the WHO report in 2020, over 17 million eligible children did not receive the first dose of DPT-containing vaccine and about 6 million infants were partially vaccinated due to lack of access to vaccination and other health services.⁸

There is significant intra and inter-country variation in access to vaccines.¹⁰ Coverage varies widely among and within countries, especially in marginalized populations which include conflict-tone areas, slums and others.¹¹ Further, geographical variations in vaccination uptake have been noted, especially between the rural and urban communities. Significant disparities have been reported in the coverages of health services including vaccination and health outcomes, especially among individuals of different socioeconomic status, with those in urban slums affected the worst.¹¹ This has been observed in majority of the developing countries including Nigeria, Uganda, and Kenya.^12–14

Although, overall urban vaccination coverage is better than that of rural settings, the urban- poor population has specific challenges with access and utilization of the vaccination services, with consistent reports of lower vaccination coverage in those populations.¹⁵ Explaining socio-economic inequality on vaccination coverage in Nigeria, Ataguba et al reported that children from well-off households in the urban areas and wealthier regions in Nigeria have a better chance to be fully vaccinated compared with those from poor urban populations.¹⁶ Some of the unique barriers to the delivery and utilization of vaccination services include transient populations and seasonal migration, inflexible employment situations, unfavorable scheduling, and spatial placement of vaccination sessions for urban dwellers, as well as multiple cultures that require service adaptations.¹⁷

The rapid rise of urbanization around the globe underscores the relevance of understanding this subject. According to the 2014 revised United Nations (UN) report on urbanization, 54% of the population in the world was living in urban areas in 2014.¹⁸ It further projected that about 66% of the population in 2050 will be residing in urban areas.¹⁸ There are different reasons why people migrate to urban areas which include employment opportunities and access to better education, among others.¹⁹ The dramatic increase in urban population exerts pressure on the social services including health services. This essay will discuss unique challenges facing urban vaccination programs in developing countries and strategies that can be employed to improve vaccination service delivery in urban settings particularly to the urban poor population. This is crucial if we are to achieve the Immunisation Agenda 2030 ambitious goal of reaching every child with vaccines and leaving no one behind in any situation or at any stage in life.¹⁰

Challenges

Transient populations and seasonal migration

The urban poor population is extremely mobile.²⁰ Families migrate for different reasons and consequently create a barrier to continuity of care, hence place children at great risk when they do not get fully vaccinated.²¹ The unstable population in urban slums makes it difficult for health workers to estimate the target population and develop strategies for tracing defaulters.¹⁷ This leaves the significant population of infants unvaccinated or partially vaccinated thereby increasing the risk of vaccine-preventable diseases outbreaks.

Inflexible employment situation

Increase in urbanization has its own uncalled for consequences such as ever increasing urban poor dwellers.¹⁸ Most urban poor dwellers depend on the informal employment, especially in LMICs. This informal economy could be in form of small and medium enterprises or casual labor. Most of these have quite restrictive working conditions that may limit them the opportunity to utilize non-urgent health but essential services such as vaccination.²² This is because most of those require them to reach specific sales targets. Additionally, sometimes the managers can be quite stringent on letting their employees to attend other non-work-related activities. As such, they barely have time to think about or follow up on dates when they are supposed to revisit facilities for continuation of care. Parents who have marginal existence have little time to devote to child care including getting their children vaccinated.²²

Unfavorable scheduling

Vaccination sessions are usually open during working hours and working days in most low-income settings. In high-income settings, vaccines are commonly administered on an appointment basis. These inconvenient hours of operations have been renowned to be among the barriers to uptake of vaccination services in the urban poor community.¹⁴ Caretakers usually leave home early and come back late with no time to seek essential health services including vaccination unless they are sick. The traditional schedule for preventive services is rigid and fails to meet the needs of a certain section of society, especially those in poor urban settings.

Multiple culture population

Sociocultural factors have been observed to affect both vaccination uptake and participation in the vaccination activities and other preventive health services by mothers.^23,24 In most cases, urban dwellers are from diverse cultural and religious backgrounds. This heterogeneity in culture and beliefs make it difficult for one strategize how to work for all. Some health systems, especially in low-income countries, might not cope with the demands of different cultures that may require different strategies. Additionally, sociocultural factors affect implementation of other public health interventions. For instance, they were observed to have an impact on the acceptability of malaria interventions in pregnant women in Africa.²⁵

Strategies to improve urban poor population vaccination uptake

Effective community engagement

Involving communities in designing health care intervention strategies has improved community participation and uptake. In most settings, the increasing knowledge of the site and timing of vaccination to the community has been associated with increased uptake in vaccination.²⁶ Community participation in the planning, delivery, and monitoring of routine vaccination is effective in reducing the number of unvaccinated children and improving the timeliness of subsequent doses. Traditional and religious leaders have been noted to be an underutilized resource in this regard.²⁷ Vaccination programs should, therefore, be able to utilize community structures and develop tailor-made strategies to the urban poor community to improve vaccination service delivery.

Employing multiple vaccination strategies and sites

In most low-income settings like southern African countries, vaccines are provided on static and outreach clinics only. Most of these are scheduled on specific dates. If the schedule is canceled for any reason, that denies children the opportunity of getting vaccinated in that instance. Even in high-income settings, routine vaccination appointments have been canceled before citing the COVID-19 pandemic among reasons.²⁸ Having multiple vaccination strategies and opening non-traditional sites for vaccination have proved effective elsewhere, including reducing the distance that caregivers walk to have their children vaccinated.¹⁵ For instance, to improve yellow fever vaccination uptake in Brazil, health authorities provided vaccination at football matches. Furthermore, in Malawi, to improve uptake of the COVID-19 vaccines, different strategies were implemented in line with Malawi’s 2021 Enhanced COVID-19 Vaccine Deployment Plan. These included the following: mobile vaccination using mobile vans; opening vaccination sites at busy places like markets, churches, big malls, bus deports, stadia; and providing vaccines on weekends when people are free; “Vaccine Express” where healthcare workers were going to remote areas with the vaccine and provide it to whomever were willing to get the vaccine. In short, public health authorities took the service to the people.²⁹

Adaptive and flexible immunisation services

With rapid urban population growth, vaccination programs around the world need to adapt policies and strategies to meet needs of the mobile and more diverse poor urban population especially those living in slums.³⁰ These strategies would include providing flexible opening hours as well as innovative ways to trace defaulters. Additionally, service providers could extend opening hours by setting up vaccination sessions during weekends and public holidays. This would enable individuals with restrictive working conditions to access the services. Furthermore, service providers should strive to reduce the missed opportunity for vaccination and reduce waiting times.²² On strategies to improve vaccination rates, Hambidge et al reported that multimodal interventions increased the number of children reached with a vaccination program.³¹ Some of the interventions in the multimodal approach included calling for those who missed appointments, assistance with transportation services and the use of reminder cards, just to mention a few.³¹ This would require a health system that is adaptive to the needs of the people it serves. In its 5.0 Strategy 2021–2025, GAVI, the Vaccine Alliance, has shown commitment to assist countries to strengthen their health systems to reach all under-vaccinated children and communities with vital vaccines.³² Governments could take advantage of the GAVI funds and develop adaptive and flexible vaccination programs that respond to the needs of everyone including those living in urban slums.

Conclusion

Vaccination remains a powerful tool against infectious diseases. However, the urban poor due to their unique social circumstances are at a disadvantage when it comes to access preventive health services particularly vaccination in comparison to the rural and affluent society counter parts. Informal employment, frequent migration, unfavorable vaccine schedules make it extremely difficult for the urban poor to find time to follow up on appointments for vaccination as well as health care workers to map high risk areas and trace defaulters. However, active community engagement, multifaceted vaccination strategies, adaptable and flexible immunization services can help to increase awareness on where and when immunization services are available, provide services at times when urban poor are home and trace defaulters. This is not an exhaustive list of interventions that can work. Therefore, stakeholders in vaccination programs should consider the context they are working in and employ strategies that can work to leave no one behind with vaccination and primary health care as is prescribed in the Immunization Agenda 2030.

Disclosure statement

BZ was working as WHO Malawi Country Office Malaria Vaccine Technical Officer. SM was working as a WHO Malawi Country Office Polio and Supplementary Immunization Activities Officer. FB and TM have no interests to declare. However, content of this commentary reflects their own opinions not that of their, then, employers.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.