Addressing Missed Opportunities for Vaccination in N’Gabacoro Droit, Mali

Background

The N’Gabacoro Droit Health Area has seen persistent challenges in childhood immunization, including a high rate of missed opportunities for vaccination (MOV). These issues were compounded by health system inefficiencies, caregiver misconceptions, and limited integration between curative and preventive services.

The findings of this study offered a comprehensive view into the persistent gaps that prevent full immunization coverage despite a functional vaccine supply system. Through community engagement and direct interviews, the project uncovered both structural and behavioral contributors to MOV. It demonstrated that knowledge deficits, among caregivers and health workers alike, are a significant barrier to completing immunization schedules. These insights form the basis for new strategies to better inform caregivers, monitor child immunization status consistently, and strengthen follow-up mechanisms across health services.

This project was implemented from January 2, 2024 to March 28, 2024 under the leadership of Moussa Kaloga, a fellow of the second cohort of Sabin and WHO’s COVID-19 Recovery for Routine Immunization Fellowship Programs. Through this fellowship, Kaloga led a targeted study to evaluate the prevalence and drivers of MOV among children aged 0–23 months.

The project aimed to generate evidence to inform local strategies for improving vaccine coverage and service delivery by identifying zero-dose and under-vaccinated children and recommending systemic improvements.

Objectives

1. Determine the number of zero-dose and under-vaccinated children aged 0–23 months
2. Identify the causes of missed opportunities for vaccination
3. Recommend interventions to reduce MOV in the health area
4. Develop a long-term plan to improve vaccination performance

Implementation Strategy

• Study Design: A cross-sectional survey involving 375 mothers/guardians and 13 health workers
• Data Collection: Conducted in February 2024 by 10 trained investigators and supervisors
• Analysis: Quantitative data were analyzed for vaccination coverage by age and vaccine type; qualitative data captured caregiver perceptions and health worker knowledge
• Stakeholder Engagement: Results shared with local stakeholders, including health center leadership, community relays, and municipal officials
• Inventory Review: Assessment of cold chain, stock management, and logistical infrastructure

Challenges and Adaptations

• Structural Constraints: Ongoing renovations at the health center created logistical disruptions
• Knowledge Gaps: Some health workers held incorrect beliefs about contraindications, contributing to MOV
• Parental Misinformation: While most mothers relied on health workers for vaccine information, low literacy, and unclear communication contributed to confusion
• No Major Delays: Project activities proceeded as planned without major adjustments

Outcomes and Impact

• Vaccination Coverage: Penta 3 coverage was lower than Penta 1 and Penta 2, indicating drop-out issues
• Zero-dose Rate: 6.15% of surveyed children had not received any Penta 3 dose; 4.55% had missed Penta 1 entirely
• Measles & Yellow Fever: Over 44% of children had not received measles (VAR) and yellow fever (VAA) vaccines
• Health Worker Knowledge: 4 out of 10 health workers identified incorrect contraindications; only 9 understood the full schedule
• System Readiness: No stockouts were reported, and cold chain equipment was functional
• Community Participation: Mothers reported being reminded about vaccinations, mainly through health workers and community relays

Results

Sample Characteristics:

Age of Children:

• Average: 9 months
• Minimum: 0 months
• Maximum: 24 months

Sex of Children:

• 51% boys, 49% girls

Vaccination Coverage Rates

Penta 1 Vaccine Administration by Age Group:

• 0-11 months: 4.55% received no dose, 0.82% received Penta 1 separately.
• 12-59 months: 3.05% received no dose, 0% received Penta 1 separately.

Penta 2 Vaccine Administration by Age Group:

• 0-11 months: 7.22% received no dose, 0.41% received Penta 2 separately.
• 12-59 months: 3.05% received no dose, 0% received Penta 2 separately.

Penta 3 Vaccine Administration by Age Group:

• 0-11 months: 16.58% received no dose, 1.23% received Penta 3 separately.
• 12-59 months: 3.05% received no dose, 0.76% received Penta 3 separately.

Measles Vaccine (VAR) Administration:

• 44.07% did not receive the VAR vaccine.

Yellow Fever Vaccine (VAA) Administration:

• 44.82% did not receive the VAA vaccine.

Human Resources Mobilized

Health Workers in N’Gabacoro Droit Health Area:

Names and responsibilities of 10 health workers listed.

Material Resources

Vaccine Stock Management as of January 31, 2023:

Detailed table of vaccine stocks, quantities received, used, and remaining, including BCG, VPO, Penta, PCV-13, VPI, Rota, VAR, VAA, MenAfriVac, Td, HPV, SAB BCG, SAB 0.5ml, and consumables like syringes and safety boxes.

Logistical Resources

• The center has a motorcycle in good condition for advanced strategy in other villages.
• Two refrigerators, one solar-powered, for vaccine storage.

Stakeholder Involvement

Roles and Responsibilities:

• The mayor, ASACO, and community relays support the center’s operation, social mobilization, cold chain, and advanced strategy financing.

Determining the Reasons for Missed Opportunities for Vaccination (MOV)

Knowledge, Attitudes, and Practices of Health Workers:

• 4/10 health workers had incorrect contraindications.
• 9/10 health workers knew the vaccination schedule.
• 10/10 health workers reported methods to remind mothers of their child’s next vaccination.

Health System Factors:

• The health area has a main center in N’Gabacoro Droit and a secondary center in Sallah.
• The center is under renovation, with a new building separating the dispensary and maternity.
• Adequate vaccination space but suboptimal amenities.
• No vaccine stockouts or supply issues in the last six months.

Parental Factors:

• 4% of children did not have vaccination cards.
• Mothers receive vaccination information from health workers and community relays.

Interventions Identified to Reduce Missed Opportunities:

• Strengthen supervision
• Ensure systematic vaccination checks during curative visits
• Enhance health worker training
• Improve community engagement

Lessons Learned

• Even with available vaccines, knowledge, and communication gaps result in missed opportunities
• Structural and logistical upgrades are essential for uninterrupted service delivery
• Health worker refresher training is critical to avoid misclassification of contraindications
• Parental trust and engagement are essential, especially for follow-up doses

Recommendations

• Strengthen supervision and mentoring for health workers
• Conduct systematic vaccination checks during all child health visits
• Expand community education using culturally tailored messages
• Integrate MOV reduction into district-level immunization planning
• Ensure continued maintenance of cold chain infrastructure

Conclusion

This evaluation highlighted that MOVs in N’Gabacoro Droit are driven not by supply issues but by gaps in health worker practices and caregiver understanding. With clear recommendations and high community engagement, the project lays a foundation for improving coverage and building a resilient immunization program. Future work will include scaling catch-up strategies and supporting lifelong vaccination initiatives throughout the district.