Are children on track with their routine immunization schedule in a fragile and protracted conflict state of South Sudan? A community-based cross-sectional study

Since 2012, total immunization coverage in South-Sudan has been around 47.5%, and till date, the country has remained a conflict-prone region [1‐3]. Data from the WHO vaccine-preventable diseases monitoring system shows that between 2017 and 2020, there has been an increasing prevalence of Measles and Rubella diseases in the country [3, 4]. The Measles outbreak in South Sudan and the increasing prevalence of vaccine-preventable diseases could be linked to the challenges with immunization access and its cold chain logistics [5]. These challenges are linked to the South Sudanese Civil War which lasted between December, 2013 and February 2020, resulting in the vandalization and looting of about 50% of the cold-chain infrastructure in the country [6]. The low coverage of vaccine-preventable diseases in South Sudan is also related to the fragile health system [1], which is bedeviled with the several challenges ranging from health workforce shortages, poor public funding of the health system, limited access to healthcare services, as well as weak vaccine surveillance and monitoring systems [7]. The upsurge in some vaccine-preventable diseases clearly indicates the need for more attention to be given to immunization in South Sudan in a bid to forestall a resultant increase in childhood mortality that could ensue. The re-emergence and increasing prevalence of vaccine-preventable diseases in some parts of South Sudan is similar to the situation in conflict-prone regions of countries such as Iraq, Syria and Yemen [8].

Arguably, children in conflict-prone regions rightfully deserve to be fully vaccinated like their peers in other parts of the world. A significant proportion of children would need to be immunized over a prolonged period for herd immunity to be attained in their region or country, and as such, the risk of a child contracting a vaccine-preventable disease is higher if more children have either not been immunized or received incomplete immunisation [9].

In accordance with global recommendations for increased vaccination coverage of at least 90% in all countries, it is imperative that vaccination coverage and completion rates in South Sudan are given high attention to ensure that the factors impeding complete vaccination coverage are identified and novel strategies employed to bridge the gap in immunization coverage [10]. This study seeks to assess if children in a conflict-prone state of South Sudan are on track with their immunization schedule and also to identify predisposing factors that could have prevented children aged 0–23 months from being on track with their routine immunization schedule.

This study analyzed the factors that influence the likelihood of children aged 0–23 living in South Sudan to be off track with their routine immunization schedule. We found that 75.5% of the participants were off track and that the percentage of off track status increased in subsequent vaccine doses. Findings similar to this were reported in a study in Ethiopia that showed decreasing immunization coverage in subsequent vaccine doses [28]. Our study found that the high proportion of off track children was driven mainly by community and state-level variables. A child who did not attend a church that discussed immunization importance was more than 2 times more likely to be off track with immunisation than children who went to a church that discussed immunization importance. A child whose community leaders did not discuss immunization importance was more than 3 times more likely to be off track than a child whose community leader did. Additionally, the probability of a child being off track was reduced by 85% when mothers and caregivers were given adequate notice about immunization outreach. This is linked to the finding that the conduct of outreach immunization was an influential factor as children without access to outreach immunization were 2 times more likely to be off track than children with access to outreach immunization. Furthermore, children who did not have vaccinators coming directly to the family livelihood business were about 70% less likely to be off track. The perceptions of mothers and caregivers was also seen to be an influential factor as children were more than 4 times more likely to be off track if they had mothers who believed that the benefit of immunization was more towards child growth than protection against disease. Additionally, children who had 6 siblings or more were up to 60% less likely to be off track compared to being an only child. In addition to community factors, we also noted that geographical factors influenced the likelihood of children being on track with their immunization in conflict-prone parts of South Sudan. This was supported by the finding that living close to health facilities and having transportation reduced a child’s chances of being off track by 85%.

Discussion about the benefits of Immunization in Churches was found to be a strong predictor of being off track with immunization. This finding highlights the role religious organizations play as influential platforms for educating the public and communicating the benefits of immunization to their worshippers. This finding contrasts with findings from a study in Nigeria which reported that religious leaders were reluctant to recommend vaccination to their followers on behalf of health authorities [29]. This reluctance to promote immunization in religious organizations could be related to the belief of some religious leaders that vaccination is against the ‘will of God’ as was reported by a study in Benin [30]. Although our study did not investigate whether and to what extent churches and worship centers are involved in immunization activities, we recommend that there is the need to review existing policies to ensure that religious organizations are involved in the planning and implementation of immunization programmes, and the monitoring of vaccine utilization at the community level. Similarly, a child whose community leader did not discuss immunization importance was over 3 times more likely to be off track than a child whose community leader did. This finding justifies the need for the active involvement of community leaders in driving immunization programme success. This finding justifies the need for the active involvement of community leaders in driving immunization programme success. The finding corroborated a study in Nigeria [31] which reported that efforts of community leaders and other community-level factors positively influenced the knowledge of mothers on immunization benefits. This finding also corroborated a study which focused on community engagement, routine immunization, and polio legacy in Northern Nigeria, a similar conflict context area with a long history of poor immunization and health performance [32]. Another study showed that the quality and volume of immunization and health information available in mothers’ social environment influenced the uptake of immunization services [33]. Based on the findings of our study, it can be deduced that the quality and volume of immunization information can be promoted through community leaders. This makes it imperative for community leaders to be more involved in promoting immunization education considering that in the absence of formal education facilities, community leaders can advance community health education, especially for girls and women. We observed that the probability of a child being off track was reduced by 85% when mothers and caregivers were given adequate notice prior to immunization outreach. This finding highlights the benefit of optimizing immunization outreaches and the provision of adequate notice to mothers and caregivers, and encourages enhanced application of immunization outreaches within our study population. The optimization of immunization outreaches was supported by a WHO report that identified inadequate prior notice to immunization as one of the barriers to vaccine utilization [34]. In order to achieve an effective immunization outreach program, a micro-plan that involves rigorous communications with community stakeholders during the pre- or post-planning process should be implemented. Existing EPI micro-plans should be reviewed for areas where services are not optimized to reflect what works best for all stakeholders. The micro-plan developed in consultation with the benefiting communities, should have social mobilization well integrated in it as outreach activity is partially determined by the robustness of social mobilizers’ commitment (see Fig. 3). Furthermore, the commitment and quality of social mobilizers should be reestablished to ensure communities, government and the donors are not being short-changed with inadequacy or non provision of services. Since social mobilizers are engaged as a matter of policy in implementing immunization outreaches, immunization programme managers should ensure that mobilizers have good knowledge of the area they are to cover, comfortable to work in these insecure areas and are accepted by their assigned community. Otherwise, the use of multiple mobilizers may be adopted by communities with wide land mass or with security challenges. Social mobilizers and EPI Vaccinators providing outreach services should be regularly supported, mentored and monitored (SMM) to improve integration and deliver quality immunization services. In this regard, we recommend not more than two to three immunization sessions per week with more days available for adequate social mobilization. Furthermore, as seen in the study’s results, children who did not have vaccinators during family livelihood business were about 70% less likely to be off track. In a study conducted in Burkina Faso, mothers who gave more concern to their business were found not to have their children with full vaccination [35]. The finding indicates that mothers/caregivers are likely to prioritize their businesses over the immunization of their children since the timing of immunization clashes with their business hours. This reiterates the usefulness of a well planned and coordinated vaccination plan with input from various interests including the working mother population.

This study observed that health facilities frequently conducting routine (static) immunization services on a daily basis were influential in reducing the amount of children off track with immunization. Policy on immunization in South Sudan advises the implementation of routine immunization outreach across communities outside the 5 km radius of a health facility [1, 36, 37]. Considering the need for improvement of immunization success in countries like South Sudan, continuous vaccine availability and punctuality of EPI vaccinators at health facilities, creation and sustainability of more outreach posts with regular supplementary immunisation activities in hard-to-reach areas could translate into higher vaccine uptake. The above mixed intervention should be evaluated regularly to ensure communities, government and the donors get appropriate service and value for immunisation programmes. While promoting staff retention is important to achieving sustained progress, vaccinators who are found deficient with low-commitment should be given refreshers’ training while those with repeated underperformance should be let go in order to engage committed ones. We also recommend the continual usage of performance incentives to pay vaccinators for services rendered; and for every falsehood identified in the immunization accountability conducts and reports, sanctions should be designed. To promote the effectiveness of performance based incentives, an improved system of accountability has to be put in place. There is an urgent need for South Sudan to put forward a clear policy and implementable strategies on training of vaccinators, and/or who should be responsible for vaccination delivery at health facilities and within communities. State immunization performance monitoring and evaluation strategy must be reviewed at least twice in a year, and interventions should be fashioned to model collaborative, iterative and inclusive and targeted problem solving approaches. According to a unicef report, a ‘one-size-fits-all’ approach in this changing world is no longer appropriate [38]. Nevertheless, analysis of data available from DHIS2 have shown more vaccination still takes place during outreaches activities for most counties in south Sudan [1, 39].

When it came to mothers/ caregivers and their thoughts towards immunization, children had a higher odds of being off track if they had mothers who believed the benefits of immunization is for child growth compared to protection against diseases. Extensive evidence has also consistently listed child protection from diseases as a primary benefit from complete vaccination of children [40, 41]. Interestingly, our sampled mothers place higher value on good child growth as the benefit of immunization rather than protection against diseases to their children. In this regard, we recommend educating caregivers on the benefits of immunization as it has a great influence on immunization uptake (see Fig. 3).

In this study, it was noted that mothers who had 6 or more children had a lower odds of being off track compared to those whose mothers had one child. Studies conducted in Liberia and another in Kenya showed a reduced chance of completion of vaccination for children with 2–3 siblings but the chance of completion increased for children with 4 siblings and above, when compared to one child only [42]. Studies conducted in Liberia and another in Kenya showed a reduced chance of completion of vaccination for children with 2–3 siblings but the chance of completion increased for children with 4 siblings and above, when compared to one child only. This finding is contrary to the reports from Eastern Ethiopia (OR 3.55, CI: 1.32–9.58) [43] and West Africa that showed higher odds of defaulting from immunization with mothers of higher parity [44].

Not only was the outcome dependent on community factors, but also geographical factors in that living close to health facilities and having transportation reduced a child’s chances of being off track by 85%. This finding demonstrates the importance of health equity and increasing immunization access to hard-to-reach and far communities. This study finding is in line with a study conducted in Kenya that showed mothers residing about > 5 km from a health facility (OR 1.6, CI1.1–3.1) were more likely to default from completing vaccination [42]. Contrarily, studies conducted in Mali (OR:0.6, CI: 0.4–0.8) and Niger (OR: 0.8, 0.6–1.0), showed that living closer to health facilities was not associated with complete vaccination of children [44]. Activities that positively influence health seeking behaviour and immunization information sharing should be promoted to optimise immunization service utilization. While it may be a good recommendation based on the study finding for government and partners to establish more health facilities considering its potential benefits to immunization and population health generally, location and localization of health facilities are governed by other factors including population and resources which may not immediately support that. Hence, a proper assessment of the health (facility) needs is highly recommended. Political influence in the positioning of health facilities should be minimized if it cannot be completely stopped. Robust implementation and coordination between the health facility, outreach and mobile immunisation services should be urgently considered as they could be ideal in reducing the amount the caregivers use in transportation costs.

In all, this study has revealed that improving immunization coverage requires strengthening community health systems, and this should remain a key priority for government and major health partners.

This study showed that a high proportion of children are off track with their immunization schedule and this is mainly driven by factors linked to immunization service delivery mechanisms at community and state levels. These factors include but are not limited to sub-optimal communication about immunization by religious organizations and community leaders, inadequate notice of outreach immunization to mothers/care-givers, limited reach of of outreach vaccination, the perceptions of mothers/care-givers’ towards immunization, and travel distance to health facilities. Based on the findings of our study, we recommended potential interventions to improve child immunization uptake in South Sudan. The findings of this study are not likely to be transferable to a non-conflict context, nevertheless, we strongly recommend regular evaluation of the performance of health system vaccine delivery at the community level.