Beyond the Clinic Gate: Barriers to Childhood Immunization Access and Strategies for Improvement at a Rural Zimbabwean Clinic

Beyond the Clinic Gate: Barriers to Childhood Immunization Access and Strategies for Improvement at a Rural Zimbabwean Clinic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond the Clinic Gate: Barriers to Childhood Immunization Access and Strategies for Improvement at a Rural Zimbabwean Clinic Eustina Shava, Faith Chiwungwe, Miriam Chitura This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9039262/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Childhood immunization through the Expanded Programme on Immunization (EPI) remains central to reducing vaccine-preventable disease morbidity and mortality in sub-Saharan Africa. Zimbabwe's national EPI coverage for pentavalent 3 stood at 83% in 2023, below the 90% global target. Nyaure Clinic in Goromonzi District, Mashonaland East Province, recorded coverage of 65%, 62%, and 67% for pentavalent 3 in 2021, 2022, and 2023 respectively. This study investigated factors affecting access to EPI services at Nyaure Clinic and identified strategies to improve coverage. Methods A quantitative cross-sectional survey design was used. The study population comprised 261 caregivers, 10 community health workers (CHWs), and 3 nurses in the Nyaure catchment area. A stratified random sample of 61 participants was selected using the Raosoft sample size calculator at a 90% confidence level. Data were collected in October 2024 using structured, self-administered questionnaires. Descriptive analysis was performed using Microsoft Excel and results are presented in tables and figures. Results Of 61 respondents, 95% were female. Among caregivers (n = 55), 96% reported receiving information about EPI, with 71% citing health facility workers as the primary source. Vaccines were reported as unavailable 14.36% of the time. Distance was identified as a barrier by 29% of caregivers and 100% of health workers. Religious and cultural beliefs, particularly among Apostolic sects, were identified as contributing to vaccine hesitancy. Poverty and political interference were not perceived as barriers. The leading strategies proposed by caregivers were outreach programmes (93%), health education (71%), and door-to-door vaccination (58%). All health workers (100%) endorsed outreach programmes, health education, door-to-door vaccination, building more clinics, legislation against vaccine hesitancy, and CHW recruitment as improvement strategies. Conclusions Distance, religious and cultural beliefs, intermittent vaccine shortages, and the absence of legislation penalising vaccine hesitancy are the primary barriers to EPI access at Nyaure Clinic. Intensified outreach programmes, health education, door-to-door vaccination, and policy reform are needed to improve coverage. These findings have implications for EPI programme managers, district health teams, and policymakers across rural Zimbabwe. Expanded Programme on Immunization childhood vaccination vaccine hesitancy healthcare access Zimbabwe rural health barriers to immunization Background Vaccination is one of the most cost-effective public health interventions for preventing infectious disease morbidity and mortality in children under five years of age [ 1 ]. The Expanded Programme on Immunization (EPI), launched by the World Health Organization (WHO) in 1974, was designed to ensure equitable access to life-saving vaccines for every child regardless of geographic location or socioeconomic status [ 2 ]. Over five decades, EPI has grown from protecting children against six diseases to offering 13 universally recommended vaccines across the life course [ 3 ]. Despite this progress, immunization coverage remains below target in many low- and middle-income countries. In 2023, globally 14.5 million children received no vaccines, defined as zero-dose children, and coverage of diphtheria, tetanus, and pertussis third dose (DTP3) stood at 84%, below the 90% global target [ 4 ]. In sub-Saharan Africa, DTP3 coverage varies from 56% to 97% across countries, and more than 30 million children under five continue to suffer from vaccine-preventable diseases (VPDs) annually, with over half a million dying each year [ 4 , 5 ]. In Zimbabwe, EPI services are offered nationwide with support from WHO, GAVI, and UNICEF. Nonetheless, national DTP3 (pentavalent 3) and measles-rubella first dose (MR1) coverage each stood at 83% in 2023, below the 90% target [ 4 ]. Goromonzi District in Mashonaland East Province is among five Zimbabwean districts that have not attained pentavalent 3 coverage above 80% according to the District Health Information Software (DHIS2). Within this district, Nyaure Clinic recorded pentavalent 3 coverage of 65%, 62%, and 67% in 2021, 2022, and 2023 respectively, and MR1 coverage of 55%, 50%, and 55% in the same years. The clinic also recorded the highest number of confirmed measles cases in Goromonzi District during the 2022 national measles outbreak. Low immunization coverage compromises herd immunity, increases the risk of VPD outbreaks, contributes to child disability and death, and places economic strain on health systems [ 6 ]. Understanding the specific barriers operating at facility and community level is essential to designing targeted interventions. Previous studies have identified distance, socio-demographic factors, maternal education, religious and cultural beliefs, vaccine availability, and health worker practices as determinants of immunization uptake in sub-Saharan Africa [ 7 , 8 , 9 ]. However, evidence on the specific barriers operating at Nyaure Clinic and the strategies most acceptable to the community and health workers in this context is lacking. This study aimed to: (1) determine caregivers' knowledge of EPI services; (2) identify barriers to EPI access at Nyaure Clinic; (3) describe health workers' perspectives on causes of low coverage; and (4) identify strategies to improve EPI coverage at Nyaure Clinic in Goromonzi District, Zimbabwe. Methods Study design and setting A quantitative cross-sectional survey was conducted at Nyaure Clinic in Goromonzi District, Mashonaland East Province, Zimbabwe. Goromonzi is a predominantly rural district located approximately 45 kilometres east of Harare. Nyaure Clinic serves a catchment population of 261 caregivers of children under five, 10 community health workers (CHWs), and 3 nurses. Data were collected over two weeks in October 2024. Study population and sampling The target population comprised caregivers of children under five years, CHWs, and nurses within the Nyaure catchment area. From the caregiver population of 261, a sample size of 55 participants was determined using the Raosoft sample size calculator at a 90% confidence level and a significance level of 0.1. All 10 CHWs and all 3 nurses were included. However, because nurses and CHW questionnaires were combined for health worker analysis, 6 health workers completed questionnaires. The final sample was 61 participants. Stratified random sampling was used to ensure proportional representation of all sub-groups. Each participant had an equal probability of selection. Data collection instruments Three structured, self-administered questionnaires were developed specifically for this study: one for nurses, one for caregivers, and one for CHWs (see Additional file 1). Questionnaires contained closed-ended items covering demographic characteristics, knowledge of EPI, barriers to vaccination access, vaccine availability, distance, religious and cultural beliefs, and strategies to improve coverage. The questionnaires were pilot-tested with 10 respondents and refined based on feedback. Research supervisors reviewed the instruments to ensure content validity. Questionnaires were administered in October 2024 following approval from the Medical Research Council of Zimbabwe (MRCZ/B/2795) and the Makumbe Hospital ethical review board. Data analysis Completed questionnaires were grouped by similar responses for computation. Data were entered into and analysed using Microsoft Excel. Results are presented as frequencies and percentages in tables and figures. Descriptive statistics are reported for all study variables. Ethical considerations Ethical approval was obtained from the Medical Research Council of Zimbabwe (MRCZ/B/2795) and Makumbe Hospital. Written permission was obtained from the District Medical Officer. Informed consent was obtained from all participants before data collection. Participants were informed of the study purpose, their right to withdraw at any time, and the confidentiality of their responses. No personal identifying information was collected. Participation was voluntary. Results Response rate and demographic characteristics All 61 questionnaires distributed were completed and returned, yielding a 100% response rate. Table 1 shows the sex distribution of respondents. Of all respondents (n = 61), 57 (95%) were female and 3 (5%) were male. Among caregivers (n = 55), 54 were female and one was male. Table 1 Sex distribution of respondents (N = 61) Respondent group Male Female Total Caregivers 1 54 55 Community health workers 1 2 3 Nurses 1 2 3 Total 3 57 61 CHW = Community health worker Among caregivers, the 25 to 31 years age group was the most represented. Young mothers aged 18 to 31 years accounted for 58.1% of caregivers. Most caregivers (63.64%) had attained secondary education, and 58% were not formally employed. Health workers ranged in age from 32 years to 39 years and above, all had attained at least secondary education, all nurses held a Primary Care Nurse (PCN) qualification, and all health workers had served in the Nyaure catchment area for five or more years. Knowledge of EPI services Of the 55 caregivers, 96% reported having received information about the importance of EPI services, while 3.64% had not. Figure 4 (see below) summarises these findings. Of those who received information, 71% cited health facility workers as the primary source. Village health workers and public media accounted for the remaining sources. Ninety-one percent of caregivers reported having received EPI education during antenatal or postnatal care visits. All 6 health workers (100%) reported discussing EPI coverage with caregivers most often. Availability of vaccines Among caregivers, 83.64% reported that vaccines were available at Nyaure Clinic most of the time. However, 14.36% reported that vaccines were sometimes not available. This intermittent non-availability was identified as a contributing factor to low coverage. Barriers to EPI access Distance was identified as a barrier to EPI access by 29% of caregivers (n = 55) and 100% of health workers (n = 6). The majority of caregivers (71%) did not regard distance as a barrier, though the health workers consistently identified areas within the catchment that were far from the facility, served by poor terrain and limited public transport. Religious and cultural beliefs, particularly those of Apostolic sects, were identified as contributing to vaccine hesitancy and low coverage. Poverty and political interference were not perceived as barriers by caregivers or health workers. Young maternal age (18 to 31 years accounting for 58.1% of caregivers) was noted as a socio-demographic factor potentially associated with lower vaccination uptake, consistent with evidence that younger mothers are less likely to vaccinate their children than older mothers [ 10 ]. Strategies to improve EPI coverage Table 2 shows the strategies proposed by caregivers to increase EPI access. Outreach programmes were the most commonly endorsed strategy (51 caregivers, 93%), followed by health education (71%) and door-to-door vaccination (58%). Building more clinics was endorsed by 18% of caregivers. Table 2 Strategies to increase EPI access as proposed by caregivers (N = 55) Strategy Outreach programmes Health education Door-to-door vaccination Building more clinics Table 3 shows strategies proposed by health workers (n = 6). All health workers (100%) endorsed outreach programmes, continuous health education, door-to-door vaccination, building more clinics, enacting legislation that criminalises vaccine hesitancy, and training more CHWs. Fifty percent endorsed vaccination awareness campaigns in churches. Table 3 Strategies to increase EPI access as proposed by health workers (N = 6) Strategy Frequency (n) Percentage (%) Outreach programmes 6 100 Continuous health education 6 100 Door-to-door vaccination 6 100 Building more clinics 6 100 Legislation criminalising vaccine hesitancy 6 100 Training more community health workers 6 100 Vaccination awareness campaigns in churches 3 50 Discussion This study investigated barriers to EPI access and strategies for improvement at Nyaure Clinic, a rural primary healthcare facility in Goromonzi District, Zimbabwe, where pentavalent 3 coverage has remained between 62% and 67% for three consecutive years. The findings identify distance, intermittent vaccine shortages, religious and cultural beliefs, young maternal age, and the absence of legislation penalising vaccine hesitancy as key barriers, while outreach, health education, and policy reform are the most consistently endorsed improvement strategies. Knowledge of EPI services The high level of EPI awareness among caregivers (96%) is encouraging and reflects the active information dissemination role of health workers at Nyaure Clinic. Health facility workers were the primary source of EPI information for 71% of caregivers. This finding aligns with Ota et al. (2022), who demonstrated that maternal knowledge of vaccine benefits directly influences vaccination uptake and that positive attitudes toward vaccine safety are crucial for coverage improvement [ 11 ]. However, 9% of caregivers reported receiving EPI information from public media, a source that during the COVID-19 pandemic contributed substantially to vaccine misinformation and hesitancy [ 12 ]. This proportion, though small, warrants targeted media engagement strategies. High knowledge levels did not translate directly into high coverage at Nyaure Clinic, suggesting that structural and social barriers operate independently of awareness. This is consistent with findings by Bangura et al. (2020) in a systematic review of sub-Saharan African settings, which identified supply-side and community-level factors as co-determinants of coverage alongside knowledge [ 7 ]. Barriers to EPI access Distance emerged as a barrier for 29% of caregivers and all health workers. The discrepancy between these proportions may reflect the health workers' direct knowledge of geographically remote villages within the catchment area. Nyaure Clinic is in a rural setting served by poor road infrastructure and limited public transport. This finding is consistent with Israel (2016)'s observation that rural residents face greater barriers to healthcare access than urban residents due to infrastructure deficits and service availability [ 13 ]. The WHO Reach Every Child (REC) strategy specifies that children within three kilometres of a facility should access routine services at the facility, those within five kilometres should be served through outreach, and those beyond ten kilometres through mobile clinics [ 14 ]. The persistent coverage deficit at Nyaure Clinic suggests these thresholds are not being met for a proportion of the catchment population. Intermittent vaccine shortages, reported by 14.36% of caregivers, represent a modifiable supply-side barrier. Vaccine stock-outs disrupt immunization schedules and reduce caregiver confidence in facility services. District-level EPI coordinators bear responsibility for ensuring consistent cold chain maintenance and stock availability at peripheral facilities. Religious and cultural beliefs, specifically those of Apostolic sects, were identified as contributing to vaccine hesitancy. This aligns with Joslyn and Sylvester (2019), who documented how religious conviction and cultural norms shape vaccine acceptance and parental decision-making [ 15 ]. Apostolic sect vaccine refusal has been documented in prior Zimbabwean literature and represents a community-specific barrier requiring culturally sensitive engagement strategies. Contrary to the literature, poverty and political interference were not perceived as barriers by either caregivers or health workers at this site. This finding diverges from Israel (2016), who identified poverty as a determinant of health service access [ 13 ]. A possible explanation is that the predominantly rural, subsistence-farming population in Nyaure has flexible time availability for clinic visits, and that financial cost is not a direct barrier since EPI services are offered free of charge. This context-specific finding underscores the importance of locally grounded research rather than generalising from broader literature. The preponderance of young caregivers (58.1% aged 18 to 31 years) is consistent with Islam et al. (2021)'s finding that younger maternal age is associated with lower vaccination uptake, potentially due to lower appreciation of vaccine-preventable disease consequences and less accumulated experience with the health system [ 10 ]. Strategies to improve EPI coverage Both caregivers and health workers converged on outreach programmes, health education, and door-to-door vaccination as priority strategies. These findings are consistent with the broader literature. Siddiqui et al. (2022) identified outreach, educational interventions, reminder systems, and multicomponent approaches as effective strategies for improving vaccination coverage [ 16 ]. Brewer et al. (2017) found that mass vaccination campaigns, communication campaigns, and provider-coordinated quality improvement also contribute to coverage gains [ 17 ]. Hambidge et al. (2014) demonstrated that reminder and recall systems combined with feedback and incentives improve rates in disadvantaged populations [ 18 ]. A notable finding is that all health workers endorsed legislation criminalising vaccine hesitancy as an improvement strategy. This reflects frontline frustration with persistent refusal among Apostolic sect communities and mirrors global debates about mandatory vaccination policies. While legislative approaches have shown effectiveness in some high-income countries, their implementation in low-resource settings requires careful attention to community trust, human rights considerations, and enforcement capacity [ 19 ]. The call to build additional clinics to ensure that all community members live within three kilometres of a facility echoes WHO's REC strategy and reflects awareness of the structural infrastructure deficit in the catchment area. This finding carries resource implications that require government prioritisation. Limitations This study has several limitations that should be considered when interpreting the findings. First, the sample was drawn from a single clinic catchment area, which restricts generalisability to other rural Zimbabwean or sub-Saharan African settings. Second, the sample size of 61, while statistically determined at a 90% confidence level, is small; findings should therefore be treated as indicative rather than definitive. Third, self-administered questionnaires with closed-ended items may introduce social desirability bias and precluded exploration of the depth and nuance of participant experiences; a mixed-methods design incorporating in-depth interviews would have strengthened the evidence. Fourth, the study relied on caregiver self-report for vaccine receipt and perceived barriers, which may not accurately reflect actual vaccination status or the full range of barriers operating in the catchment area. Fifth, the cross-sectional design captures a single point in time and cannot establish causal relationships between identified barriers and low coverage. Sixth, the health worker sub-group was small (n = 6), limiting the weight that can be placed on findings specific to that group. Future research should use a larger, multi-site design and incorporate qualitative methods to capture caregiver and community narratives around vaccine hesitancy. Conclusions EPI coverage at Nyaure Clinic has remained persistently below national and global targets for three consecutive years. This study identified distance to the health facility, intermittent vaccine shortages, religious and cultural beliefs, young maternal age, and the absence of legislation penalising vaccine hesitancy as perceived barriers to immunization access in this rural Zimbabwean setting. Notably, high caregiver awareness of EPI benefits did not correspond with adequate coverage, suggesting that structural and social barriers may operate independently of knowledge, though the cross-sectional design of this study does not permit causal conclusions. Health workers and caregivers consistently endorsed outreach programmes, health education, door-to-door vaccination, and CHW expansion as priority improvement strategies. These findings suggest that policymakers and district health managers should consider strengthening outreach services, ensuring consistent vaccine supply at peripheral facilities, and investing in healthcare infrastructure to reduce travel distances. District EPI coordinators, nursing managers, and community health workers each have roles to play in translating these strategies into coverage improvements. Given the study’s limitations, further research using larger, multi-site designs is needed before broader recommendations can be made with confidence. Declarations Ethics approval and consent to participate: Ethical approval was granted by the Medical Research Council of Zimbabwe (MRCZ/B/2795) and the Makumbe Hospital ethics committee. All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki (1964) and its subsequent revisions. Written permission was obtained from the Goromonzi District Medical Officer. All participants provided informed written consent prior to data collection. Participation was voluntary and confidentiality was assured. Clinical trial number: Not applicable. Consent for publication: Not applicable. No individual participant data, images, or other personal data are included in this article. Availability of data and materials: The dataset supporting the conclusions of this article is included within the article and its additional file(s). Competing interests: The authors declare that they have no competing interests. Funding: This study received no external funding. It was conducted as part of the requirements for the Bachelor of Science Honours Degree in Nursing Science at Zimbabwe Open University. Authors' contributions: ES conceptualised and designed the study, collected data, conducted analysis, and drafted the manuscript. FC supervised the study design, analysis, and critical revision of the manuscript. MC critical review of the manuscript. All authors read and approved the final manuscript. Acknowledgements: The authors thank the caregivers, community health workers, and nurses at Nyaure Clinic who gave their time to participate in this study. The authors also thank the Goromonzi District Medical Officer for permission to conduct the research. References Montero DA, Vidal RM, Velasco J, Carreño LJ, Torres JP, Benachi OMA, et al. Two centuries of vaccination: historical and conceptual approach and future perspectives. Front Public Health. 2024;11:1326154. Pong K, Sopheab H, Chau D. Determinants of complete basic childhood vaccination among children aged 12–35 months in Cambodia. Cambodia J Public Health. 2025;6. World Health Organization. Status of immunization coverage in Africa as of the end of 2022. World Health Organization. Regional Office for Africa; 2023. Kaur G. Routine vaccination coverage—worldwide, 2022. MMWR Morb Mortal Wkly Rep. 2023;72. Okesanya OJ, Olatunji G, Olaleke NO, Mercy MO, Ilesanmi AO, Kayode HH, et al. Advancing immunization in Africa: overcoming challenges to achieve the 2030 global immunization targets. Adolesc Health Med Ther. 2024;8:83–91. Kutz JM, Rausche P, Gheit T, Puradiredja DI, Fusco D. Barriers and facilitators of HPV vaccination in sub-Saharan Africa: a systematic review. BMC Public Health. 2023;23(1):974. Ogundele OA, Ogunwemimo HS, Fehintola FO, Ogundele T, Olorunsola A, Bello OE, et al. Predictors of incomplete childhood vaccination in four West African countries: a population based cross-sectional study. Sci Rep. 2025;15(1):17119. Abegaz MY, Seid A, Awol SM, Hassen SL. Determinants of incomplete child vaccination among mothers of children aged 12–23 months in Worebabo district, Ethiopia: unmatched case-control study. PLOS Glob Public Health. 2023;3(8):e0002088. Hobani F, Alhalal E. Factors related to parents’ adherence to childhood immunization. BMC Public Health. 2022;22(1):819. Akanpaabadai EA, Adiak AA, Nukpezah RN, Adokiya MN, Adjei SE, Boah M. Population-based cross-sectional study of factors influencing full vaccination status of children aged 12–23 months in a rural district of the Upper East Region, Ghana. BMC Pediatr. 2024;24(1):168. Ota MO, De Moraes JC, Vojtek I, Constenla D, Doherty TM, Cintra O, et al. Unveiling the contributions of immunization for progressing towards universal health coverage. Hum Vaccin Immunother. 2022;18(1):2036048. Baggio M, Krawczyk MW, Nohlen H, Pantazi M, Proestakis A. Applying lessons from behavioural sciences to vaccination acceptance and demand. 2022. Brammli-Greenberg S, Hovav B. Unmet needs and the effect of healthcare system generosity on prevention activity–a multilevel analysis. Soc Sci Med. 2024;340:116473. World Health Organization. Implementation guide for vaccination of health workers. World Health Organization; 2022. Nassar O, Alshahwan S, Alshahwan R, Halasa S, Alashhab S, Alnajar M. Determinants of parents’ knowledge, attitudes, and practice toward childhood vaccination: a national study. Open Nurs J. 2023;17(1). Siddiqui FA, Padhani ZA, Salam RA, Aliani R, Lassi ZS, Das JK, et al. Interventions to improve immunization coverage among children and adolescents: a meta-analysis. Pediatrics. 2022;149(Supplement 6):e2021053852D. Micek K, Hester KA, Chanda C, Darwar R, Dounebaine B, Ellis AS, et al. Critical success factors for routine immunization performance: a case study of Zambia 2000 to 2018. Vaccine X. 2022;11:100166. Zhu J, Cole CB, Fihman J, Adjagba A, Dasic M, Cernuschi T. Opportunities to accelerate immunization progress in middle-income countries. Vaccine. 2024;42:S98–106. Nassar O, Alshahwan S, Alshahwan R, Halasa S, Alashhab S, Alnajar M. Determinants of parents’ knowledge, attitudes, and practice toward childhood vaccination: a national study. Open Nurs J. 2023;17(1). Additional Declarations No competing interests reported. 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The Expanded Programme on Immunization (EPI), launched by the World Health Organization (WHO) in 1974, was designed to ensure equitable access to life-saving vaccines for every child regardless of geographic location or socioeconomic status [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Over five decades, EPI has grown from protecting children against six diseases to offering 13 universally recommended vaccines across the life course [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite this progress, immunization coverage remains below target in many low- and middle-income countries. In 2023, globally 14.5\u0026nbsp;million children received no vaccines, defined as zero-dose children, and coverage of diphtheria, tetanus, and pertussis third dose (DTP3) stood at 84%, below the 90% global target [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In sub-Saharan Africa, DTP3 coverage varies from 56% to 97% across countries, and more than 30\u0026nbsp;million children under five continue to suffer from vaccine-preventable diseases (VPDs) annually, with over half a million dying each year [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Zimbabwe, EPI services are offered nationwide with support from WHO, GAVI, and UNICEF. Nonetheless, national DTP3 (pentavalent 3) and measles-rubella first dose (MR1) coverage each stood at 83% in 2023, below the 90% target [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Goromonzi District in Mashonaland East Province is among five Zimbabwean districts that have not attained pentavalent 3 coverage above 80% according to the District Health Information Software (DHIS2). Within this district, Nyaure Clinic recorded pentavalent 3 coverage of 65%, 62%, and 67% in 2021, 2022, and 2023 respectively, and MR1 coverage of 55%, 50%, and 55% in the same years. The clinic also recorded the highest number of confirmed measles cases in Goromonzi District during the 2022 national measles outbreak.\u003c/p\u003e \u003cp\u003eLow immunization coverage compromises herd immunity, increases the risk of VPD outbreaks, contributes to child disability and death, and places economic strain on health systems [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Understanding the specific barriers operating at facility and community level is essential to designing targeted interventions. Previous studies have identified distance, socio-demographic factors, maternal education, religious and cultural beliefs, vaccine availability, and health worker practices as determinants of immunization uptake in sub-Saharan Africa [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, evidence on the specific barriers operating at Nyaure Clinic and the strategies most acceptable to the community and health workers in this context is lacking.\u003c/p\u003e \u003cp\u003eThis study aimed to: (1) determine caregivers' knowledge of EPI services; (2) identify barriers to EPI access at Nyaure Clinic; (3) describe health workers' perspectives on causes of low coverage; and (4) identify strategies to improve EPI coverage at Nyaure Clinic in Goromonzi District, Zimbabwe.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA quantitative cross-sectional survey was conducted at Nyaure Clinic in Goromonzi District, Mashonaland East Province, Zimbabwe. Goromonzi is a predominantly rural district located approximately 45 kilometres east of Harare. Nyaure Clinic serves a catchment population of 261 caregivers of children under five, 10 community health workers (CHWs), and 3 nurses. Data were collected over two weeks in October 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population and sampling\u003c/h3\u003e\n\u003cp\u003eThe target population comprised caregivers of children under five years, CHWs, and nurses within the Nyaure catchment area. From the caregiver population of 261, a sample size of 55 participants was determined using the Raosoft sample size calculator at a 90% confidence level and a significance level of 0.1. All 10 CHWs and all 3 nurses were included. However, because nurses and CHW questionnaires were combined for health worker analysis, 6 health workers completed questionnaires. The final sample was 61 participants. Stratified random sampling was used to ensure proportional representation of all sub-groups. Each participant had an equal probability of selection.\u003c/p\u003e\n\u003ch3\u003eData collection instruments\u003c/h3\u003e\n\u003cp\u003eThree structured, self-administered questionnaires were developed specifically for this study: one for nurses, one for caregivers, and one for CHWs (see Additional file 1). Questionnaires contained closed-ended items covering demographic characteristics, knowledge of EPI, barriers to vaccination access, vaccine availability, distance, religious and cultural beliefs, and strategies to improve coverage. The questionnaires were pilot-tested with 10 respondents and refined based on feedback. Research supervisors reviewed the instruments to ensure content validity. Questionnaires were administered in October 2024 following approval from the Medical Research Council of Zimbabwe (MRCZ/B/2795) and the Makumbe Hospital ethical review board.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eCompleted questionnaires were grouped by similar responses for computation. Data were entered into and analysed using Microsoft Excel. Results are presented as frequencies and percentages in tables and figures. Descriptive statistics are reported for all study variables.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003ewas obtained from the Medical Research Council of Zimbabwe \u003cb\u003e(MRCZ/B/2795)\u003c/b\u003e and Makumbe Hospital. Written permission was obtained from the District Medical Officer. Informed consent was obtained from all participants before data collection. Participants were informed of the study purpose, their right to withdraw at any time, and the confidentiality of their responses. No personal identifying information was collected. Participation was voluntary.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eResponse rate and demographic characteristics\u003c/h2\u003e \u003cp\u003eAll 61 questionnaires distributed were completed and returned, yielding a 100% response rate. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the sex distribution of respondents. Of all respondents (n\u0026thinsp;=\u0026thinsp;61), 57 (95%) were female and 3 (5%) were male. Among caregivers (n\u0026thinsp;=\u0026thinsp;55), 54 were female and one was male.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSex distribution of respondents (N\u0026thinsp;=\u0026thinsp;61)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespondent group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCHW = Community health worker\u003c/h3\u003e\n\u003cp\u003eAmong caregivers, the 25 to 31 years age group was the most represented. Young mothers aged 18 to 31 years accounted for 58.1% of caregivers. Most caregivers (63.64%) had attained secondary education, and 58% were not formally employed. Health workers ranged in age from 32 years to 39 years and above, all had attained at least secondary education, all nurses held a Primary Care Nurse (PCN) qualification, and all health workers had served in the Nyaure catchment area for five or more years.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge of EPI services\u003c/h2\u003e \u003cp\u003eOf the 55 caregivers, 96% reported having received information about the importance of EPI services, while 3.64% had not. Figure\u0026nbsp;4 (see below) summarises these findings. Of those who received information, 71% cited health facility workers as the primary source. Village health workers and public media accounted for the remaining sources. Ninety-one percent of caregivers reported having received EPI education during antenatal or postnatal care visits. All 6 health workers (100%) reported discussing EPI coverage with caregivers most often.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAvailability of vaccines\u003c/h2\u003e \u003cp\u003eAmong caregivers, 83.64% reported that vaccines were available at Nyaure Clinic most of the time. However, 14.36% reported that vaccines were sometimes not available. This intermittent non-availability was identified as a contributing factor to low coverage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to EPI access\u003c/h2\u003e \u003cp\u003eDistance was identified as a barrier to EPI access by 29% of caregivers (n\u0026thinsp;=\u0026thinsp;55) and 100% of health workers (n\u0026thinsp;=\u0026thinsp;6). The majority of caregivers (71%) did not regard distance as a barrier, though the health workers consistently identified areas within the catchment that were far from the facility, served by poor terrain and limited public transport.\u003c/p\u003e \u003cp\u003eReligious and cultural beliefs, particularly those of Apostolic sects, were identified as contributing to vaccine hesitancy and low coverage. Poverty and political interference were not perceived as barriers by caregivers or health workers. Young maternal age (18 to 31 years accounting for 58.1% of caregivers) was noted as a socio-demographic factor potentially associated with lower vaccination uptake, consistent with evidence that younger mothers are less likely to vaccinate their children than older mothers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrategies to improve EPI coverage\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the strategies proposed by caregivers to increase EPI access. Outreach programmes were the most commonly endorsed strategy (51 caregivers, 93%), followed by health education (71%) and door-to-door vaccination (58%). Building more clinics was endorsed by 18% of caregivers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStrategies to increase EPI access as proposed by caregivers (N\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutreach programmes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor-to-door vaccination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuilding more clinics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows strategies proposed by health workers (n\u0026thinsp;=\u0026thinsp;6). All health workers (100%) endorsed outreach programmes, continuous health education, door-to-door vaccination, building more clinics, enacting legislation that criminalises vaccine hesitancy, and training more CHWs. Fifty percent endorsed vaccination awareness campaigns in churches.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStrategies to increase EPI access as proposed by health workers (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutreach programmes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinuous health education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor-to-door vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuilding more clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLegislation criminalising vaccine hesitancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining more community health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaccination awareness campaigns in churches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated barriers to EPI access and strategies for improvement at Nyaure Clinic, a rural primary healthcare facility in Goromonzi District, Zimbabwe, where pentavalent 3 coverage has remained between 62% and 67% for three consecutive years. The findings identify distance, intermittent vaccine shortages, religious and cultural beliefs, young maternal age, and the absence of legislation penalising vaccine hesitancy as key barriers, while outreach, health education, and policy reform are the most consistently endorsed improvement strategies.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge of EPI services\u003c/h2\u003e \u003cp\u003eThe high level of EPI awareness among caregivers (96%) is encouraging and reflects the active information dissemination role of health workers at Nyaure Clinic. Health facility workers were the primary source of EPI information for 71% of caregivers. This finding aligns with Ota et al. (2022), who demonstrated that maternal knowledge of vaccine benefits directly influences vaccination uptake and that positive attitudes toward vaccine safety are crucial for coverage improvement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, 9% of caregivers reported receiving EPI information from public media, a source that during the COVID-19 pandemic contributed substantially to vaccine misinformation and hesitancy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This proportion, though small, warrants targeted media engagement strategies.\u003c/p\u003e \u003cp\u003eHigh knowledge levels did not translate directly into high coverage at Nyaure Clinic, suggesting that structural and social barriers operate independently of awareness. This is consistent with findings by Bangura et al. (2020) in a systematic review of sub-Saharan African settings, which identified supply-side and community-level factors as co-determinants of coverage alongside knowledge [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to EPI access\u003c/h2\u003e \u003cp\u003eDistance emerged as a barrier for 29% of caregivers and all health workers. The discrepancy between these proportions may reflect the health workers' direct knowledge of geographically remote villages within the catchment area. Nyaure Clinic is in a rural setting served by poor road infrastructure and limited public transport. This finding is consistent with Israel (2016)'s observation that rural residents face greater barriers to healthcare access than urban residents due to infrastructure deficits and service availability [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The WHO Reach Every Child (REC) strategy specifies that children within three kilometres of a facility should access routine services at the facility, those within five kilometres should be served through outreach, and those beyond ten kilometres through mobile clinics [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The persistent coverage deficit at Nyaure Clinic suggests these thresholds are not being met for a proportion of the catchment population.\u003c/p\u003e \u003cp\u003eIntermittent vaccine shortages, reported by 14.36% of caregivers, represent a modifiable supply-side barrier. Vaccine stock-outs disrupt immunization schedules and reduce caregiver confidence in facility services. District-level EPI coordinators bear responsibility for ensuring consistent cold chain maintenance and stock availability at peripheral facilities.\u003c/p\u003e \u003cp\u003eReligious and cultural beliefs, specifically those of Apostolic sects, were identified as contributing to vaccine hesitancy. This aligns with Joslyn and Sylvester (2019), who documented how religious conviction and cultural norms shape vaccine acceptance and parental decision-making [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Apostolic sect vaccine refusal has been documented in prior Zimbabwean literature and represents a community-specific barrier requiring culturally sensitive engagement strategies.\u003c/p\u003e \u003cp\u003eContrary to the literature, poverty and political interference were not perceived as barriers by either caregivers or health workers at this site. This finding diverges from Israel (2016), who identified poverty as a determinant of health service access [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A possible explanation is that the predominantly rural, subsistence-farming population in Nyaure has flexible time availability for clinic visits, and that financial cost is not a direct barrier since EPI services are offered free of charge. This context-specific finding underscores the importance of locally grounded research rather than generalising from broader literature.\u003c/p\u003e \u003cp\u003eThe preponderance of young caregivers (58.1% aged 18 to 31 years) is consistent with Islam et al. (2021)'s finding that younger maternal age is associated with lower vaccination uptake, potentially due to lower appreciation of vaccine-preventable disease consequences and less accumulated experience with the health system [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrategies to improve EPI coverage\u003c/h2\u003e \u003cp\u003eBoth caregivers and health workers converged on outreach programmes, health education, and door-to-door vaccination as priority strategies. These findings are consistent with the broader literature. Siddiqui et al. (2022) identified outreach, educational interventions, reminder systems, and multicomponent approaches as effective strategies for improving vaccination coverage [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Brewer et al. (2017) found that mass vaccination campaigns, communication campaigns, and provider-coordinated quality improvement also contribute to coverage gains [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hambidge et al. (2014) demonstrated that reminder and recall systems combined with feedback and incentives improve rates in disadvantaged populations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA notable finding is that all health workers endorsed legislation criminalising vaccine hesitancy as an improvement strategy. This reflects frontline frustration with persistent refusal among Apostolic sect communities and mirrors global debates about mandatory vaccination policies. While legislative approaches have shown effectiveness in some high-income countries, their implementation in low-resource settings requires careful attention to community trust, human rights considerations, and enforcement capacity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe call to build additional clinics to ensure that all community members live within three kilometres of a facility echoes WHO's REC strategy and reflects awareness of the structural infrastructure deficit in the catchment area. This finding carries resource implications that require government prioritisation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. First, the sample was drawn from a single clinic catchment area, which restricts generalisability to other rural Zimbabwean or sub-Saharan African settings. Second, the sample size of 61, while statistically determined at a 90% confidence level, is small; findings should therefore be treated as indicative rather than definitive. Third, self-administered questionnaires with closed-ended items may introduce social desirability bias and precluded exploration of the depth and nuance of participant experiences; a mixed-methods design incorporating in-depth interviews would have strengthened the evidence. Fourth, the study relied on caregiver self-report for vaccine receipt and perceived barriers, which may not accurately reflect actual vaccination status or the full range of barriers operating in the catchment area. Fifth, the cross-sectional design captures a single point in time and cannot establish causal relationships between identified barriers and low coverage. Sixth, the health worker sub-group was small (n\u0026thinsp;=\u0026thinsp;6), limiting the weight that can be placed on findings specific to that group. Future research should use a larger, multi-site design and incorporate qualitative methods to capture caregiver and community narratives around vaccine hesitancy.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eEPI coverage at Nyaure Clinic has remained persistently below national and global targets for three consecutive years. This study identified distance to the health facility, intermittent vaccine shortages, religious and cultural beliefs, young maternal age, and the absence of legislation penalising vaccine hesitancy as perceived barriers to immunization access in this rural Zimbabwean setting. Notably, high caregiver awareness of EPI benefits did not correspond with adequate coverage, suggesting that structural and social barriers may operate independently of knowledge, though the cross-sectional design of this study does not permit causal conclusions.\u003c/p\u003e \u003cp\u003eHealth workers and caregivers consistently endorsed outreach programmes, health education, door-to-door vaccination, and CHW expansion as priority improvement strategies. These findings suggest that policymakers and district health managers should consider strengthening outreach services, ensuring consistent vaccine supply at peripheral facilities, and investing in healthcare infrastructure to reduce travel distances. District EPI coordinators, nursing managers, and community health workers each have roles to play in translating these strategies into coverage improvements. Given the study\u0026rsquo;s limitations, further research using larger, multi-site designs is needed before broader recommendations can be made with confidence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval was granted by the Medical Research Council of Zimbabwe \u003cstrong\u003e(MRCZ/B/2795)\u003c/strong\u003e and the Makumbe Hospital ethics committee. All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki (1964) and its subsequent revisions. Written permission was obtained from the Goromonzi District Medical Officer. All participants provided informed written consent prior to data collection. Participation was voluntary and confidentiality was assured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable. No individual participant data, images, or other personal data are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe dataset supporting the conclusions of this article is included within the article and its additional file(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study received no external funding. It was conducted as part of the requirements for the Bachelor of Science Honours Degree in Nursing Science at Zimbabwe Open University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003eES conceptualised and designed the study, collected data, conducted analysis, and drafted the manuscript. FC supervised the study design, analysis, and critical revision of the manuscript. MC critical review of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors thank the caregivers, community health workers, and nurses at Nyaure Clinic who gave their time to participate in this study. The authors also thank the Goromonzi District Medical Officer for permission to conduct the research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMontero DA, Vidal RM, Velasco J, Carre\u0026ntilde;o LJ, Torres JP, Benachi OMA, et al. Two centuries of vaccination: historical and conceptual approach and future perspectives. Front Public Health. 2024;11:1326154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePong K, Sopheab H, Chau D. Determinants of complete basic childhood vaccination among children aged 12\u0026ndash;35 months in Cambodia. Cambodia J Public Health. 2025;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Status of immunization coverage in Africa as of the end of 2022. World Health Organization. Regional Office for Africa; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur G. Routine vaccination coverage\u0026mdash;worldwide, 2022. MMWR Morb Mortal Wkly Rep. 2023;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkesanya OJ, Olatunji G, Olaleke NO, Mercy MO, Ilesanmi AO, Kayode HH, et al. Advancing immunization in Africa: overcoming challenges to achieve the 2030 global immunization targets. Adolesc Health Med Ther. 2024;8:83\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKutz JM, Rausche P, Gheit T, Puradiredja DI, Fusco D. Barriers and facilitators of HPV vaccination in sub-Saharan Africa: a systematic review. BMC Public Health. 2023;23(1):974.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgundele OA, Ogunwemimo HS, Fehintola FO, Ogundele T, Olorunsola A, Bello OE, et al. Predictors of incomplete childhood vaccination in four West African countries: a population based cross-sectional study. Sci Rep. 2025;15(1):17119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbegaz MY, Seid A, Awol SM, Hassen SL. Determinants of incomplete child vaccination among mothers of children aged 12\u0026ndash;23 months in Worebabo district, Ethiopia: unmatched case-control study. PLOS Glob Public Health. 2023;3(8):e0002088.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHobani F, Alhalal E. Factors related to parents\u0026rsquo; adherence to childhood immunization. BMC Public Health. 2022;22(1):819.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkanpaabadai EA, Adiak AA, Nukpezah RN, Adokiya MN, Adjei SE, Boah M. Population-based cross-sectional study of factors influencing full vaccination status of children aged 12\u0026ndash;23 months in a rural district of the Upper East Region, Ghana. BMC Pediatr. 2024;24(1):168.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOta MO, De Moraes JC, Vojtek I, Constenla D, Doherty TM, Cintra O, et al. Unveiling the contributions of immunization for progressing towards universal health coverage. Hum Vaccin Immunother. 2022;18(1):2036048.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaggio M, Krawczyk MW, Nohlen H, Pantazi M, Proestakis A. Applying lessons from behavioural sciences to vaccination acceptance and demand. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrammli-Greenberg S, Hovav B. Unmet needs and the effect of healthcare system generosity on prevention activity\u0026ndash;a multilevel analysis. Soc Sci Med. 2024;340:116473.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Implementation guide for vaccination of health workers. World Health Organization; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNassar O, Alshahwan S, Alshahwan R, Halasa S, Alashhab S, Alnajar M. Determinants of parents\u0026rsquo; knowledge, attitudes, and practice toward childhood vaccination: a national study. Open Nurs J. 2023;17(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiddiqui FA, Padhani ZA, Salam RA, Aliani R, Lassi ZS, Das JK, et al. Interventions to improve immunization coverage among children and adolescents: a meta-analysis. Pediatrics. 2022;149(Supplement 6):e2021053852D.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMicek K, Hester KA, Chanda C, Darwar R, Dounebaine B, Ellis AS, et al. Critical success factors for routine immunization performance: a case study of Zambia 2000 to 2018. Vaccine X. 2022;11:100166.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu J, Cole CB, Fihman J, Adjagba A, Dasic M, Cernuschi T. Opportunities to accelerate immunization progress in middle-income countries. Vaccine. 2024;42:S98\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNassar O, Alshahwan S, Alshahwan R, Halasa S, Alashhab S, Alnajar M. Determinants of parents\u0026rsquo; knowledge, attitudes, and practice toward childhood vaccination: a national study. Open Nurs J. 2023;17(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Expanded Programme on Immunization, childhood vaccination, vaccine hesitancy, healthcare access, Zimbabwe, rural health, barriers to immunization","lastPublishedDoi":"10.21203/rs.3.rs-9039262/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9039262/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChildhood immunization through the Expanded Programme on Immunization (EPI) remains central to reducing vaccine-preventable disease morbidity and mortality in sub-Saharan Africa. Zimbabwe's national EPI coverage for pentavalent 3 stood at 83% in 2023, below the 90% global target. Nyaure Clinic in Goromonzi District, Mashonaland East Province, recorded coverage of 65%, 62%, and 67% for pentavalent 3 in 2021, 2022, and 2023 respectively. This study investigated factors affecting access to EPI services at Nyaure Clinic and identified strategies to improve coverage.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA quantitative cross-sectional survey design was used. The study population comprised 261 caregivers, 10 community health workers (CHWs), and 3 nurses in the Nyaure catchment area. A stratified random sample of 61 participants was selected using the Raosoft sample size calculator at a 90% confidence level. Data were collected in October 2024 using structured, self-administered questionnaires. Descriptive analysis was performed using Microsoft Excel and results are presented in tables and figures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf 61 respondents, 95% were female. Among caregivers (n\u0026thinsp;=\u0026thinsp;55), 96% reported receiving information about EPI, with 71% citing health facility workers as the primary source. Vaccines were reported as unavailable 14.36% of the time. Distance was identified as a barrier by 29% of caregivers and 100% of health workers. Religious and cultural beliefs, particularly among Apostolic sects, were identified as contributing to vaccine hesitancy. Poverty and political interference were not perceived as barriers. The leading strategies proposed by caregivers were outreach programmes (93%), health education (71%), and door-to-door vaccination (58%). All health workers (100%) endorsed outreach programmes, health education, door-to-door vaccination, building more clinics, legislation against vaccine hesitancy, and CHW recruitment as improvement strategies.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDistance, religious and cultural beliefs, intermittent vaccine shortages, and the absence of legislation penalising vaccine hesitancy are the primary barriers to EPI access at Nyaure Clinic. Intensified outreach programmes, health education, door-to-door vaccination, and policy reform are needed to improve coverage. These findings have implications for EPI programme managers, district health teams, and policymakers across rural Zimbabwe.\u003c/p\u003e","manuscriptTitle":"Beyond the Clinic Gate: Barriers to Childhood Immunization Access and Strategies for Improvement at a Rural Zimbabwean Clinic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 20:04:14","doi":"10.21203/rs.3.rs-9039262/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-25T09:50:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322291319893481385337857746753206944877","date":"2026-04-02T23:58:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200617316658424937843565712266620397259","date":"2026-04-02T11:19:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-31T15:47:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-25T10:11:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-16T11:01:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-14T08:41:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-14T08:37:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b926f9f8-d423-404e-95a2-a9bc11a3682e","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T20:04:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 20:04:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9039262","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9039262","identity":"rs-9039262","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}