The Final Mile – a global organisation that integrates behavioural and data science with human-centred design to address public health and development challenges – has explored whether the pandemic played a role in this and, if so, how?
Its Africa lead, Sangiwe Moyo, outlines the findings.
Over the past 20 years South Africa steadily expanded the number of diseases covered by its immunisation programme for young children.
Although rates of immunisation were a bit below target, routine immunisation was a successful chapter in the country’s chequered healthcare story. But, since the advent of the Covid-19 pandemic, the rate of children routinely receiving vaccines to prevent diseases such as polio, diphtheria and measles has dropped substantially.
Is this just an after-effect of the general decline in non-emergency visits to clinics and doctors that began as Covid-19 raged? Or is it more directly linked to the unprecedented public debate on Covid-19 vaccines that was characterised by a strong strain of misinformation?
The latter saw people develop powerful opinions on immunisation, a topic they had scarcely thought about before.
Earlier this year, the Final Mile began to explore the reasons through a small qualitative study in South Africa. Its researchers interviewed 50 parents of pre-school children, a dozen healthcare workers and a number of people who help administer the Expanded Programme on Immunisation (EPI).
Participants were based in Gauteng, KwaZulu-Natal and Mpumalanga.Their experiences and opinions helped not only to connect the drop in childhood immunisation to the Covid-19 pandemic, but also to identify individual links in the chain binding the two.
Over the years, immunisation has become a pillar of care for young children. In South Africa, most mothers would not neglect their baby’s jabs or polio drops any more than they would deprive their child of food. Immunisation has been a norm so strong that it didn’t need discussion.
“I just take my child to the clinic, they do whatever, then I come back,” a parent interviewed in the study explained. “But I don’t know the procedure, how it works, what it’s for and stuff.”
In clinics dealing with large numbers of clients, the immunisation system is set up for maximum efficiency not for individualised attention or providing information.
“They categorise us – the six months kids, the three weeks kids. And once they have grouped us, they must tell us: you guys, today your kids are going to get this injection. But they don’t say that. They just say: three months – in this door, six months in this door, and nine months in that door.
"It’s just that there is no communication between nurses and mothers,” another parent commented.
There are definite signs that parents are no longer satisfied with this approach and that Covid has been the catalyst. “I was telling myself how do I know, maybe they are telling me that this vaccine is to prevent measles, whereas you find it is the Covid vaccine that they are giving the child without informing me . . . When it comes to the Covid vaccine, many of us are reluctant, we don’t want it.”
The norm in terms of who decides whether a child is to be vaccinated seems to have shifted.
More parents appear to be making these decisions actively since Covid and are unwilling to default into trusting the health worker.Covid-19 also undermined the established practice of regular clinic visits for young children.
In the face of a high risk of Covid transmission in places such as crowded waiting rooms, mothers were advised to avoid visiting a health facility except in an emergency – and they followed this advice. Their children were mostly healthy in the absence of clinic visits. This was hardly surprising since children were staying at home and observing social distancing, mask-wearing and improved handwashing.
But the healthiness of their children in the absence of vaccination got parents thinking about the necessity of jabs. Furthermore, participants could not picture the possibility of a child getting polio, measles or diphtheria because these diseases have become so rare in the age of mass immunisation.
While this has long been a challenge for routine immunisation programmes, the perceived risk of childhood diseases faded even further compared to the very real presence of Covid. Some mothers said they trusted to luck, good genes or strong natural immunity to keep childhood diseases at bay – and continued to skip clinic visits.
Other parents decided to make up for lost jabs and their clinic experiences were not always positive. In some cases, they found that there were stock-outs of vaccines or shortages of staff. In other cases, they felt that the health worker judged them for the delayed immunisation, or their own guilt made them uncomfortable.
These factors reinforced the parents’ inclination to delay or avoid immunisation – or pass the buck to the pre-school facility to get the job done!
The South African research has helped Final Mile clarify the questions to be explored, as follows:
The importance of understanding these matters cannot be overemphasised. Immunisation has been one of the most potent public-health weapons of the last century.
The World Health Organization calculates that immunisation averts some four million deaths every year. We cannot permit unmanaged consequences of Covid-19 to destroy this safety net.