Using community-based, participatory qualitative research to identify determinants of routine vaccination drop-out for children under 2 in Lilongwe and Mzimba North Districts, Malawi

Objective In recent years, full childhood routine immunisation coverage has fallen by 5% to levels not seen since 2008; between 2019 and 2021, 67 million children were undervaccinated. We aimed to identify and describe the determinants of vaccination drop-out from the perspectives of caregivers and health workers in Malawi.Design We used a community-based participatory research approach to collect data through photo elicitation, short message service exchanges, in-depth interviews and observations. We used a team-based approach for thematic analysis, guided by the Behavioural and Social Drivers of Vaccination framework.Setting The study was conducted in Lilongwe and Mzimba North Districts in Malawi, representing urban and rural settings, respectively.Participants Participants included caregivers of partially vaccinated (n=38) and fully vaccinated (n=12) children between 25 and 34 months and Community Health Workers (n=20) who deliver vaccines. Caregiver participants were identified through health facility vaccination registers and with the assistance of community health volunteers.Results We identified five principal drivers of routine vaccination drop-out: (1) poor caregiver knowledge of the vaccine schedule and how many vaccines are needed for full vaccination; (2) caregivers’ fear of repercussions after not following vaccination guidelines; (3) rumours and concerns if vaccines are repeated or new ones are introduced; (4) high opportunity cost of health facility visits, exacerbated by wait times, stockouts and missed opportunities and (5) limited family support and vaccination burden placed largely on mothers. Key differences between rural and urban settings related to practices around health cards and vaccine wastage, wait times, migrant and tenant communities, and social support systems.Conclusions Immunisation interventions should be tailored to address drivers of drop-out in the community, the health facility and beyond. Service quality, timeliness and reliability need to be improved, and tailored messaging and education are needed, especially in response to COVID-19-related misinformation and introductions of new, routine vaccines

Impact of pharmacy worker training and deployment on access to essential medicines for children under five in Malawi: a cluster quasi-experimental evaluation

Abstract Background Poor access to essential medicines is common in many low- and middle-income countries, partly due to an insufficient and inadequately trained workforce to manage the medicines supply chain. We conducted a prospective impact evaluation of the training and deployment of pharmacy assistants (PAs) to rural health centers in Malawi. Methods A quasi-experimental design was used to compare access to medicines in two districts where newly trained PAs were deployed to health centers (intervention) and two districts with no trained PAs at health centers (comparison). A baseline household survey and two annual post-intervention household surveys were conducted. We studied children under five years with a history of fever, cough and difficulty in breathing, and diarrhea in the previous two weeks. We collected data on access to antimalarials, antibiotics and oral rehydration salts (ORS) during the childrens’ symptomatic periods. We used difference-in-differences regression models to estimate the impact of PA training and deployment on access to medicines. Results We included 3974 children across the three rounds of annual surveys: 1840 (46%) in the districts with PAs deployed at health centers and 2096 (53%) in districts with no PAs deployed at health centers. Approximately 80% of children had a fever, nearly 30% had a cough, and 43% had diarrhea in the previous two weeks. In the first year of the program, the presence of a PA led to a significant 74% increase in the odds of access to any antimalarial, and a significant 49% increase in the odds of access to artemisinin combination therapies. This effect was restricted to the first year post-intervention. There was no effect of presence of a PA on access to antibiotics or ORS. Conclusion The training and deployment of pharmacy assistants to rural health centers in Malawi increased access to antimalarial medications over the first year, but the effect was attenuated over the second year. Pharmacy assistants training and deployment demonstrated no impact on access to antibiotics for pneumonia or oral rehydration salts for diarrhea

Insights Before Flights: How Community Perceptions Can Make or Break Medical Drone Deliveries

Drones are increasingly used to transport health products, but life-saving interventions can be stalled if local community concerns and preferences are not assessed and addressed. In order to inform the introduction of drones in new contexts, this paper analyzed similarities and differences in community perceptions of medical delivery drones in Malawi, Mozambique, the Democratic Republic of the Congo (DRC) and the Dominican Republic (DR). Community perceptions were assessed using focus group discussions (FGDs) and key informant interviews (KIIs) conducted with stakeholders at the national level, at health facilities and in communities. Data were collected on respondents’ familiarity with drones, perceptions of benefits and risks of drones, advice on drone operations and recommendations on sharing information with the community. The comparative analysis found similar perceptions around the potential benefits of using drones, as well as important differences in the perceived risks of flying drones and culturally appropriate communication mechanisms based on the local context. Because community perceptions are heavily influenced by culture and local experiences, a similar assessment should be conducted before introducing drone activities in new areas and two-way feedback channels should be established once drone operations are established in an area. The extent to which a community understands and supports the use of drones to transport health products will ultimately play a critical role in the success or failure of the drone’s ability to bring life-saving products to those who need them