Social influence
Supportive kin recognising the benefits of immunisation were essential to the child being immunised. In this study setting the decision to go for immunisation was generally a joint decision between the mother and father of the child. Most study participants (FGDs and KIIs) strongly emphasized that both the child's mother and father were responsible for the immunisation of the child, but in reality, only women were in charge of taking children for immunisation. Below, we present the influences on the mother's behaviour from her social context, first her male partner, second the older generation such as mothers-in-law, fathers-in-law, sisters-in-law, and lastly her peers.
Most women expressed support from their partners when taking the child for immunisation, such as money for transport and a granted permission to take the child for immunisation. This support was reiterated by male participants; both KII and FGD participants.
'As for me, I make sure that when my wife is pregnant she attends the antenatal clinic as required and is also immunised because she usually tells me when she is immunised. Also after she gives birth I make sure she takes the children for immunisation on the dates written on the immunisation card.' (FGD with fathers)
A minority of male participants rejected immunisation however and therefore hindered their wives from immunising their children.
'My wife is pregnant but she has not been immunised. She has a four year old child and she talks about immunising the child but I stop her from doing it. For me I don't believe in it. As you can see I am a mature person but I did not grow up because of that (immunisation). It was better for me to use traditional medicine to treat fever for example, but because these days the fever is very strong I now use tablets (for treatment). Even these injections (from immunisation) paralyze people I know, and we also see them in books and in pictures.' (FGD with fathers)
If a father disagreed to immunisation, the mothers expressed less power for decision making at the household level which made them unable to take their children for immunisation. They said that it was the man's prerogative to make the decision to immunise the child. So if the father of the child stopped them from taking children for immunisation then they would not immunise their children. The women who felt this way were mainly young and with lower level of education. They believed they should submit to the men's directives at all times.
'Because the wife fears the husband, if you give me instructions never to leave the home, can I leave it? I will have broken a rule.' (FGD with younger mothers)
If a child fell sick it would be the mothers who would spend 'sleepless nights' while the men slept or went to work. Some women, mostly in FGDs with older mothers, therefore made decisions to immunise their children despite opposition and threats from their husbands, and they stressed that this has to be done with determination.
'Also, it is the mother who should really make sure your child is immunised. If you follow the man's advice and you don't immunise your child, when that child falls sick it is you the mother who will spend sleepless nights when the child is sick. He will be snoring and the doctors will abuse you as he is not around the hospital. Yet you followed his advice. You the mother have to stick to your guns. Let him fight with you, but after your child has been immunised.' (FGD with older mothers)
Some women who opposed their husbands' decision not to immunise reported that they had to be discreet about the whole process of immunisation. One female key informant told how she pretended she was going to the market, but went to the nearby outreach centre for immunisation. This 'rebellious' behaviour had consequences such as intimate partner violence which included emotional, verbal and physical violence. The violence after immunisation was experienced by a minority of women both in the FGDs and KIIs. However, all female participants in the FGDs and KIIs reported it since they had witnessed or heard about this occurrence. An older mother in tears reported an incident after her child got the first injection on the thigh, 'the baby cried all night'. Her husband sent her and the baby out of the house in the night saying it was her decision to immunise the child and he could not tolerate the noise.
Even amidst spousal violence some women derived satisfaction from the fact that their children were immunised particularly the older women that had disobeyed the husband's instructions and they intended to take their children for subsequent immunisations.
Only women who were convinced about the benefits of immunisation were willing to endure the consequences of opposing their spouses.
'The mother will say, "Let me immunise my children for their good because when my child is disabled, my husband can have other children with another woman. It is me to suffer with my children who would have helped me in future." (Female key informant)
It was reported by participants in FGDs and KIIs that if the father was against immunisation it was also common to be influenced from his elder relatives and personal experiences.
'Like I explained before about some elderly women who claim children will become lame after immunisation, some men use that excuse because they had ever heard of it while still young. So when they grow up and get children they say the children will become lame or get brain damage. That is why you see some children when they get measles they almost die because the husband refused the wife to take children for immunisation.' (FGD with older mothers)
The men who disagreed to immunisation were put under pressure by his elderly relatives and they had strong union.
'Like for the old people who have previously heard that children died, when you tell them that you are taking a child for immunisation, they will not like it. No, his father will tell him that why did you let her take the child for immunisation. And he will answer that I refused her but she insisted.' (FGD with older mothers)
The older generation exerted influence on the mother's behaviour indirectly through the husband as shown above, and also directly. For instance, the younger mothers were persuaded to take their children for immunisation against spousal consent by older experienced women in their neighbourhood. They were supported in breaking some household rules to protect the wellbeing of their children. However, older women were sometimes not supportive of young women. This was highlighted by one of the female key informants in charge of community mobilisation. She reported that teenage mothers were stigmatized by the older women who laughed at them for giving birth at an 'early age'. In addition some teenage mothers were told by the older women in their community that the fathers of their children were HIV positive. These younger mothers therefore stayed away from all immunisation activities where it was possible to meet these older women from whom they faced social stigma.
Female participants felt that mostly men had a non-conforming attitude towards childhood immunisation. So they described these men as having 'weak brains', lazy, and irresponsible. This was also reflected among male participant's judgement against those that did not immunise children: terms like they are 'ignorant' or 'uneducated' were used to describe them. The female respondents especially felt that this non-conforming attitude should have consequences. They stressed that individuals in this category should be given some form of punishment by the government. Some male respondents were in agreement with the women because they reasoned that these individuals were cruel to the innocent children whose future they were 'sabotaging' or 'ruining' by refusing immunisation. Other men strongly opposed the idea of punishment however arguing that it would be difficult to identify such individuals in the community.
In general, both FGDs and KIIs supported that the mother was under strong social influence affecting decision making on immunisation.
Self -efficacy
Not only the mother's social context influenced immunisation behaviour, but also her own ability to overcome barriers, defined as self-efficacy, affected behaviour. Major hindrances reported included financial deprivation which made the cost of going for immunisation a considerable decision to make.
'If I don't have food, how can I use Uganda shillings 2000 (approximately US$1) for a boda-boda (means of transport using motorcycle/bicycle) to go for immunisation?' (FGD with younger mothers)
With lack of money, walking could be the only alternative with distances of up to 4 km and having to cross two motor highways in some instances. This was reported from all FGD participants as a major challenge especially for women in the post-partum period if they needed to take their children for immunisation. This challenge was compounded by frequent reports by mothers and fathers that they were not given the anticipated services due to vaccines being out of stock or due to absent health workers.
Another expense for the mothers was not only financial, but also related to time. Vaccination could easily take one day and they would have lost the potential income for that day.
'The nature of work for some people at times makes them miss these immunisation schedules since somebody leaves home at around 6.00 a.m. and comes back at around 6.00 p.m. During the day this person is at the stone quarry (work place) about 2 kms from here, now the person will not take the child for immunisation although the person will be willing to take the child.' (FGD with fathers)
It was reported from Female FGDs especially that poor mothers often felt stigmatised and bullied from other women and health workers if they did not show up in good clothing or with presentable clothes or shawl for their children.
'Some young women fear going for immunisation because they don't have a baby shawl for carrying the children to hospital so when you reach at the hospital with some sheets which are not clean some nurses will sometimes begin abusing you.'(FGD with older mothers)
Gender roles were perceived as a barrier to male involvement in child immunisation activities and it was hard for the men to overcome these barriers. They would 'feel out of place' at the immunisation centres as it was considered a 'female arena.' Even if the men were willing to take their children for immunisation they did not have time to do this because they had to go for work. This competing demand for time was emphasised in all FGDs and supported by the KIIs as an important barrier to immunisation activities. Lack of job security and high unemployment rates forced parents to serve their employer if they were on private ad-hoc or longer contracts at the expense of personal activities such as taking the child for immunisation.
Attitudinal factors
The convictions of the respondents towards childhood immunisation were classified into three sub-themes: 1) trust in immunisation 2) fear of vaccine side effects 3) programmatic preferences.
Trust in immunisation
There were two opposing beliefs among our study participants: those who trusted in immunisation as a child survival strategy and those who feared or refused immunisation. Those who trusted vaccines were generally better educated and older. They recognised the diseases that could cause severe outcomes in children such as physical disability or death. These diseases were perceived by most FGD participants and key informants as common and the children as vulnerable to get the diseases unless immunised.
'When the child gets measles, he will not be bedridden. He will just get a rash or cough. He may also get red eyes or mouth rash but he will be able to play as usual. But if he was not immunised he will get very high temperatures, fever, diaorrhea and you become worried the child may even die.' (FGD with younger mothers)
The societal value of having a healthy child population was strongly held among most study participants. If their children survived vaccine preventable diseases they could contribute to building a strong society and become 'doctors and teachers who would be able to treat or teach the population.'
The fear of perceived ill effects of immunisation underpinned the strong belief against immunisation. All study participants perceived that a lack of trust towards vaccines existed among community members. Common beliefs were that vaccines were 'expired' and could cause 'physical disability and/or death' among their children. The perceived susceptibility of their children to suffer from severe effects of the vaccines led some to decline immunisation.
'At one time our neighbour in 'rural geographical area' immunised a child in the morning and by 5.00 p.m. the child was dead. From that time I fear taking children for immunisation and all my children are not immunised.' (FGD with fathers)
A lack of trust was also observed against the health personnel believed not to check the drugs properly and only give 'expired' vaccines which might cause disability or death.
Vaccine side effects
Among those who accepted the benefits of immunisation, side effects were recognised as a constraint. This fear of vaccine side effects was more commonly held among female than male respondents. Many had experienced or were afraid of vaccine side effects such as fever, temporary 'paralysis of the leg' and excessive crying after the 'first injection given on the thigh'. The consequences were either declining or delaying subsequent immunisations.
'Sometimes after immunisation children get fever and spend the whole night crying so the health worker must tell the mother in advance what will happen to the baby, "that the baby might become weak, or get a fever or the injection is painful so he will cry a lot." But some health workers don't warn the parents so when they reach home the mother will notice the child has got a fever or is crying uncontrollably. And this makes her worried.' (Male key informant)
Home remedies against side effects were frequently reported. Some treated the child with paracetamol or 'junior aspirin.' However many female FGD participants said that the side effects were persistent even after drugs were tried out, so they applied ice, cold water, onions, oranges, or 'black' shoe polish at the injection site. They explained that when the child was injected on the thigh, the vaccine remained 'stationary' at the injection site and that is why the child suffered. When applying the "black shoe polish" or any other home remedy the vaccine 'was moved' (absorbed) and the child got some relief.
Programmatic preferences
Routine immunisation was distinguished from mass immunisation services. Routine immunisation services involve individually scheduled immunisations according to the expanded programme for immunisation. Caretakers then have to bring the child to the immunisation units. On the other hand mass immunisation is the distribution of one particular or a group of vaccines meant for everybody within a certain age range in the area. It is meant to compensate for not achieving full immunisation coverage by including those who have got and those who would have missed the routine immunisation. Mass immunisation activities mostly promote measles as well as polio vaccination among children under five years and are done as community outreaches, in schools, and in conjunction with religious groups like churches. Among study respondents that accepted the benefits of immunisation, most preferred routine compared to mass immunisations because they believed that routine immunisation was 'safe'. Several reasons were fronted for preferring routine services: first, if the child developed complications after immunisation it would be easier to trace the health workers conducting routine services, which was not the case in mass immunisation services. The health worker could 'take responsibility' during routine services compared to mass immunisation services which lacked a 'fixed physical address.' Second, it was difficult for the parents to understand that there was need to take their children for further immunisations when they had completed the routine immunisation schedule. Only a few study participants had voluntarily taken their children for mass immunisation activities. The misgivings towards mass immunisation were worsened by the reported methods used to conduct the mass immunisation including officials forcefully immunising the children.