Utilization of measles immunization services among children under 5 years in Lira district, northern Uganda: a community-based cross-sectional study

Utilization of measles immunization services among children under 5 years in Lira district, northern Uganda: a community-based cross-sectional study | 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 Utilization of measles immunization services among children under 5 years in Lira district, northern Uganda: a community-based cross-sectional study Romeo Atim, Richard Nyeko, Marc Sam Opollo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7302192/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Measles remains a global health concern with high mortality rate, particularly in regions with low vaccine utilization, despite progress in measles control globally. In sub-Saharan Africa, first-dose measles vaccine utilization stands at 74%, well below the 95% target for herd immunity recommended by the World Health Organization (WHO). In northern Uganda, the proportion of children under five who receive the recommended doses of vaccines lags below the national average. This study therefore examined the level and factors influencing measles immunization utilization among children under five in Lira district, northern Uganda. Methodology This was a community-based cross-sectional study in two sub counties in Lira district, northern Uganda that utilized both quantitative and qualitative methods of data collection. We surveyed 409 children under five, selected through systematic random sampling, Data were analyzed using SPSS for univariate, bivariate, and multivariate logistic regression. Qualitative data from in-depth interviews with healthcare providers, opinion leaders, and district health officials were analyzed using thematic analysis. Ethical approval was obtained from Lira University Research and Ethics Committee. Results Measles vaccination completion was 19.6% (79/402). Factors that positively influenced utilization included antenatal (ANC) attendance (aOR = 1.65, p = 0.002), higher education level (aOR = 1.40, p = 0.023), and vaccine availability (aOR = 1.40, p = 0.020). Barriers included high transportation costs (aOR = 0.60, p = 0.010), cultural beliefs (aOR = 0.55, p = 0.006), and denial of vaccination on non-vaccination days (aOR = 0.65, p = 0.010). Qualitative findings highlighted vaccine shortages, cultural beliefs, and poor health facility access as barriers. Conclusion Measles vaccine utilization rate in the study setting of 19.6% was low. Antenatal care attendance, education level, vaccine availability, transportation costs, and cultural beliefs were key determinants of utilization. There is need develop and implement targeted strategies to address this gap, including community sensitization and health education, with emphasis of the benefits of childhood immunization in general. Utilization of Measles services Measles vaccine doses Immunization Vaccination Children Unimmunized Immunized and Lira District Figures Figure 1 Figure 2 Introduction Immunization is one of the most effective public health interventions globally, significantly reducing childhood morbidity and mortality ( 11 ). Among the vaccines, measles immunization plays a crucial role in preventing severe illness and death in children under five years. Measles is highly contagious and poses a significant threat in children with insufficient immunity. Despite global progress in measles control, with a 73% reduction in measles-related deaths from 2000 to 2019 ( 43 ), measles outbreaks remain a concern, particularly in regions with low immunization coverage. Sub-Saharan Africa continues to bear a disproportionate burden of measles cases and deaths, accounting for almost 60% of the global measles cases and three-quarter (74%) of measles-related deaths in 2019 ( 43 ). Uganda, one such country, while has had progressive decrease in the under-five mortality rate to the current 43 deaths per 1,000 live births ( 40 ), vaccine-preventable diseases, including measles, among others, remain important causes of morbidity and mortality. Although the national measles immunization coverage stands at 83% ( 40 ), there persists great regional disparity – being much lower in northern Uganda, including Lira district - exposing approximately 9,475 children under five in the district to measles-related risks ( 40 ). The Uganda National Expanded Program on Immunization (UNEPI) aims to achieve high vaccination coverage, but challenges that lead to regional and local disparities persist. Several general and context-specific factors, including demographic characteristics, infrastructure and healthcare accessibility, vaccine availability, socio-economic disparities, and cultural perceptions and beliefs, have been reported to influence immunization efforts ( 14 ). The recent evidence indicating a decline in vaccination rates in Lira district in northern Uganda, from 69% in 2021 to 58% in 2023 (DHIS2, 2023) underscores the significance of context-specific factors and the need for a focused evaluation. This study therefore examined measles immunization utilization among children under five in Lira district to understanding the barriers and facilitators of utilization which is essential for designing targeted interventions to improve utilization. Methods Study design and setting This was a community-based cross-sectional study that employed both quantitative and qualitative approaches to data collection. The study was conducted in selected villages within two sub-counties (Agali and Ogur) in Lira district, northern Uganda, between June and July 2024. Lira district is located in northern Uganda and is part of the Lango sub-region, and has an estimated population of approximately 540,000 people, about 9.475 of which are children under five years of age ( 40 ). The district has a mixed urban and rural composition, with the majority of residents engaged in subsistence farming and small-scale trade. Health services in Lira are provided through government health facilities, private clinics, and non-governmental organizations, although access remains a challenge due to infrastructure constraints and economic barriers. Study population and sample size determination The study population included children under five years in the selected villages in the two sub counties. The sample size for the quantitative data was estimated using Leslie Kish formula (1965) for single proportion, n = (Z α/2 ) 2 .pq/d 2 with a standard normal value corresponding to a 95% confidence interval (1.96), absolute errors between the estimated and true value of 5%, and an estimated proportion of measles vaccine utilization among children under 5 years of 59% ( 43 ). The estimated sample size of 372 was adjusted for a design effect of 10%, giving a total of 409. Participants for the qualitative data included selected healthcare providers, opinion leaders and officials at the district health office. Determining the number of respondents for the qualitative data collection was based on the concept of data saturation. Data saturation was reached after nine respondents, with an additional two respondents being interviewed, giving a final sample size of 11 respondents. Inclusion Criteria Children under 5 years in the selected villages of Agali and Ogur sub counties in Lira District. Exclusion Criteria Children whose caregivers declined consent were excluded from the study Sampling and study procedures We purposively selected Ogur and Agali sub counties in Erute county, Lira district, because of their reported poor utilization of immunization services ( 40 ). We then selected one parish from each of the selected sub counties using simple random sampling. All 18 villages in the selected parishes were studied. The Village Health Teams (VHTs) listed all the households (HHS) with children under 5 years in their respective villages in the selected parishes. Systematic random sampling was used to pick the HHs to be included in the study. The sampling interval was obtained by dividing the number of households by the sample size. The overall sample size for the study was 409 participants, distributed in a ratio of 1:1 for the two parishes. Given that each parish consisted of 9 villages, the average number of participants per village was calculated based on the specific household count of each village, which ranged from 70 to 90 households. We determined the starting point by throwing lot with numbers and we picked only one lot which was used as the starting point. We then sampled every fourth HHs until we got the required sample size. In cases where we didn’t find anybody at home, we attempted to come back twice before declaring them non-respondents. Data Collection Tools We used a structured interviewer-administered questionnaire to collect quantitative data. This included sociodemographic characteristics (child and caregiver), socio-economic/cultural characteristics, child’s immunization, and health system related factors. Qualitative data was collected from the respondents using an in-depth interview guide, to provide insights into the contextual and cultural factors influencing immunization decisions. The questionnaires and interview guides were developed by the investigators in line with the study objectives. These were written in English as well as translated and administered in the local language ( Leb Lango ) understood by the participants. The data collection tools were pretested to find out the suitability, ease of use, relevance of the questions, and any ambiguity so as to address the issues accordingly before the actual data collection was done. Study variables Utilization of measles immunization services was the outcome variable, and the independent variables included sociodemographic characteristics, socio-economic / cultural characteristics, and health system factors. Utilization in this study was defined as receiving measles vaccination according to the recommended national or World Health Organization (WHO) immunization schedules. Measles vaccine utilization was measured as the proportion of children under 5 years who received the recommended doses of measles-containing vaccine (MCV1 and MCV2) based on their age, as per national vaccination guidelines. Data Management and statistical analysis Quantitative data analysis Quantitative data was entered into an excel spreadsheet, cleaned, and exported to Statistical Package for Social Scientists (SPSS) (IBM) Statistics v23 for analysis. Descriptive statistics for categorical variables were presented as frequencies and percentages, while continuous variables were summarized as mean with standard deviation if normally distributed or median with interquartile range if non-normally distributed. The Chi-square test or Fischer’s exact test with Odds ratios and 95% confidence intervals were performed to determine the association between the predictor variables and utilization of measles immunization. The multivariate logistic regression model was used to assess the factors that were independently associated with utilization of measles immunization and reported by an adjusted odds ratio (aOR) at 95% confidence level. A two-sided p-value < 0.05 was considered for statistical significance. Variables that were statistically significant at the bivariate level (p < 0.05) and those with p values < 0.2 were included in the multivariate model. Qualitative data analysis Qualitative data from the in-depth interviews were analyzed using manual thematic analysis to identify key themes and patterns. The analysis followed multiple stages. First, interview recordings were transcribed verbatim and reviewed for familiarization. Initial codes were generated by identifying key phrases, concepts and patterns in the data relevant to the research objectives. Related codes were then grouped into broader themes that reflected recurring ideas in the data, which were reviewed, refined, and clearly defined. Themes were developed inductively, emerging from the data rather than being predefined. The final themes were interpreted in relation to the research objectives. Findings from the qualitative analysis were triangulated with quantitative results to provide a comprehensive and holistic understanding of factors influencing measles immunization utilization in the study context. Results were presented as themes alongside the representative quotes from participants. Ethics approval and consent to participate All methods were carried out in accordance with relevant guidelines and regulations and the study was conducted in accordance with the Declaration of Helsinki. The study was approved by Lira University Research and Ethics Committee (LUREC-2024-185). Voluntary informed consent was obtained from the parents/caretakers of the children before participating in the study after an explanation of the nature and purpose of the study, the potential benefits and risks. Results Description of the study participants During the study period, a total of 402 responses were obtained from the caregivers of children under five years, resulting in a response rate of 98.3% (402/409). The median age of the children was 24 months (interquartile range [IQR]: 12–36 months) and the majority were female, 291 (72.4%). A total of 393 (97.8%) of the children were delivered from the health facilities, and 394 (98.0%) had a child health card (simply understood by caregivers as an immunization card) available at the time of the survey (Table 1). The median age of caregivers was 30 years (IQR: 25–35 years). Most of the primary caregivers were female, 287 (71.4%) and the biological mothers of the children, 272 (67.7%). A total of 143 (35.6%) caregivers had attained a primary level of education, 201 (50.1%) had post-primary education, and 58 (14.3%) had no formal education. Up to 283 (70.4%) of the biological mothers attended antenatal care during the pregnancy with the study child. The median parity of the female caregivers was three children (Table 1). Socio-economic / cultural and Health Systems Characteristics About a third of the caregivers, 119 (29.6 %) held cultural beliefs against immunization. Transportation costs was a concern to more than one-quarter, 114 (28.4%) of the caregivers, and bicycle was the primary mode of transportation for most respondents, 244 (60.4%). At least 89 (22.1%) of the respondents had experienced unavailability of vaccines during their visits at the health facilities for vaccination. A total of 146 (36.4%) of the respondents reported being denied vaccination services at least once when they visited the facilities on non-vaccination days, and over a third, 277 (68.9%) of the respondents had experienced delay in getting vaccination services at health facilities (Table 2). Utilization of Measles Vaccine among Children Under Five Years The overall utilization of the measles vaccine among children under five years in our study population was 19.6% - 44 (11%) of whom were males and 35 (9%) were females (Figure 1). Considering the utilization of measles immunization services across different age groups, children within the age group of 25-36 months had the highest vaccination rate of 25.5%, followed by the 13-24 months age groups at 22.0% (Figure 2). Bivariate Analysis of Factors Affecting Measles Immunization Utilization The factors significantly associated with measles immunization utilization on bivariate analysis included: Parity (χ² = 2.00, p = 0.0367), antenatal care (ANC) attendance (χ² = 7.18, p = 0.007), education level (primary) (χ² = 3.50, p = 0.321), cultural beliefs about immunization (χ² = 4.75, p = 0.029), transportation costs (χ² = 0.32, p = 0.570), and vaccine availability (χ² = 4.45, p = 0.035) (Table 3). Multivariate Analysis for the Factors Associated with Utilization of Measles Immunization Services On multivariate analysis, children whose mothers attended antenatal care were 1.65 times likely to utilize measles immunization services compared to children whose mothers did not attend ANC (aOR 1.65; 95% CI 1.20-2.15, p= 0.002). Children whose caregivers had at least a primary level of education were 1.40 times likely to utilize measles immunization services compared to those whose caregivers had no formal education (aOR 1.40; 95% CI 1.05-1.85, p= 0.023). Children whose caregivers held negative cultural beliefs about immunization (aOR 0.55, 95% CI 0.40-0.76, p=0.002), had concern about transportation costs (aOR 0.60, 95% CI 0.45-0.80, p=0.010), and experienced denial of vaccination due to visiting the facility on a non-vaccination day (aOR 0.65, 95% CI 0.50-0.85, p=0.010) were less likely to utilize measles immunization services compared to their counterparts. Availability of vaccines was associated with a 1.40 times likely to utilize measles immunization services (aOR 1.40; 95% CI 1.05-1.85, p=0.020) (Table 4). Qualitative Analysis results from the Key Informant Interviews (KIIs) The qualitative component of this study aimed to explore the underlying factors affecting the utilization of measles immunization services among children under five in Lira district, northern Uganda. The analysis identified several themes that highlight the barriers and facilitators to immunization, revealing critical areas for intervention to improve utilization of measles vaccination. Five themes were identified that details the qualitative insights regarding measles vaccine utilization in the context of the study setting. Themes Identified: Awareness of measles vaccine importance The Key Informant Interviews (KIIs) revealed a widespread lack of awareness about the importance of measles vaccination among parents and guardians. Many respondents did not understand the severity of measles or the necessity of vaccination. This is exemplified by reports from two respondents below, which seems to support the finding of low measles vaccine immunization rates in the quantitative results. “Many parents do not understand the seriousness of measles and thus do not prioritize vaccination.” (A 30-year-old male respondent) “ There is generally low uptake of the measles vaccine in our community. “A 44-year-old facility in-charge” Cultural Beliefs Cultural misconceptions and traditional beliefs were identified as critical barriers to vaccination, supporting the findings from the quantitative data which showed that cultural beliefs against immunization negatively impact utilization of measles immunization services in the study setting. A common view from the respondents in the qualitative study was that some communities held beliefs that vaccinations were harmful and preferred traditional medicine over modern medical practices, as a community leader and a male teacher observed; “Some communities believe that vaccinations are harmful and rely on traditional medicine instead.” (A 55-year-old male community leader) “Educational programs targeting parents and caregivers could help in changing the attitudes towards vaccination.” (A 29-year-old male teacher) Access to Immunization Services Geographical barriers and inadequate healthcare infrastructure were frequently mentioned by the respondents as major obstacles to accessing immunization services. The distance to health facilities and high transportation costs were important issues reported to affect many families, making it difficult to access and utilize measles immunization services in the study setting, as exemplified by a statement from a 45-year-old female respondent; “The distance to the health facility and high cost of transport are major issues for many families.” Healthcare System Issues Frequent reports of vaccine stock-outs in the quantitative data were corroborated by the qualitative insights as important systemic issues within healthcare facilities that present significant barriers to consistent immunization utilization. This, coupled with the long waiting time at the health facilities to receive the immunization services are reported to demotivate some caregivers from seeking these services, as two of the respondents asserted thus; “We often face vaccine shortages, and long queues in the health facility which discourage the parents from coming for vaccinations.” (A 38-year-old female healthcare worker) “…a lack of trust in healthcare providers and the healthcare system overall is a barrier to vaccine acceptance and utilization by a number of caregiver.” (A 30-year-old female respondent) Discussion The level of uptake in Ogur and Agali was quite low (19.6%). Key study findings on utilization of measles services were antenatal care attendance, education level, vaccine availability, transportation costs, and cultural beliefs. This study investigated the level of, and the factors influencing the utilization of measles immunization services among children under five years in Lira District, northern Uganda. The findings revealed a low measles immunisation utilization, with caregivers’ education level, antenatal care (ANC) attendance, cultural beliefs regarding vaccination, socioeconomic barriers, and health facility-related factors, as key determinates. Utilization of measles vaccination Our study revealed a low level of utilization of measles immunization services in the study setting. Only about one in five children under five received the recommended doses of the measles vaccination. The level of measles immunization in the current study falls way short of the World Health Organization’s (WHO’s) target of 90% immunization utilization necessary for achieving herd immunity (43). The current finding aligns with that from other studies in similar low-resource settings. For instance, studies in Pakistan and Nigeria reported comparable results of immunization levels of 44% and 32%, respectively (12, 3). Such similarities could be attributed to common barriers in low-resource contexts, including logistical challenges and systemic issues within health facilities. Low measles immunization utilization is a well-documented issue, often exacerbated by access, misinformation, and logistical challenges (30, 26) - highlighting the need for more effective outreach and education strategies. The discrepancy between possession of an immunization card-which was high, and utilization of measles vaccination, as found in the current study, is worth noting and deserves some attention. This phenomenon, which was similarly reported in a Kenyan study, reflects a lack of understanding and appreciation of the importance of immunization and the child health cards. This could, in addition, be attributed to the fact that in Uganda, the child health card - simply known to the caregivers and the broader community as “immunization card”, are also important and used for other purposes, including enrolment in school for pre-primary and primary levels - making it a necessity to have for this face value. This underscores the need for educational and community awareness interventions (20). Antenatal care (ANC) attendance emerged as a strong predictor of measles immunization utilization in this study, with a positive association between ANC attendance and the likelihood of a child being vaccinated against measles. As similarly reported in India (4), Bangladesh (15) and Sweden – a high-income country (10), regular ANC visits are linked to enhanced health education, leading to increased vaccine uptake (4). Thus, the universal and crucial role of ANC as a platform for providing health education and raising awareness about the importance of immunization, and providing access to necessary resources, such as vaccination schedules, should be leveraged on as a targeted strategy to improve utilization of immunization services. The results from this study also highlights the impact of educational attainment on utilization of immunization services. Achieving at least a primary level of education increased the likelihood of utilizing measles immunization services. This finding accords with similar findings in Ethiopia and Nigeria, showing a positive relationship between caregivers’ higher educational levels achievement and vaccination rates (16-17). Educated mothers are more likely to comprehend the importance of vaccination and adhere to immunization schedules, a notion supported by a finding from one systematic review and meta-analysis (18). As the qualitative data also highlighted, there is a clear need for enhanced educational campaigns to improve knowledge about the benefits of immunization among parents and caregivers in this and similar contexts. Our findings also underscores the influence of culture on childhood immunization services. Strong negative cultural beliefs against immunization was a substantial barrier to utilizing measles immunization. This finding is of public health importance given its implication on the potential to drive vaccine hesitancy or refusal. The impact of culture transcends geographical and socioeconomic contexts, and is observed in low-and middle-income countries (31, 21). and developed countries alike (19). This parallel suggests that cultural beliefs, whether rooted in local traditions or broader societal narratives, can similarly impact public health interventions globally, though often overlooked in most public health interventions. On the socioeconomic front, high costs of transport to the health facility was a significant barrier to unitization of measles immunization services, underscoring the economic challenges associated with accessibility of healthcare. This finding echoes similar findings from studies in Bangladesh, South Africa and Kenya (36, 8, 32)., which identified transportation costs as a major obstacle to healthcare access, including immunization services - just as also reported in China and Congo (22, 23). The qualitative data also highlighted geographical barriers and inadequate healthcare infrastructure, suggesting a need for improved access. This should include affordable transportation options, as well as bringing immunization services closer to communities through initiatives such as community outreaches and village-level immunization posts, among others. The availability of vaccines at health facilities was another significant determinant of measles vaccine utilization among the study population. Ensuring consistent vaccine availability increased the likelihood of utilizing measles vaccination services, reflecting similar findings from South Africa and Ethiopia where frequent vaccine stock-outs and logistical issues presented major barriers to vaccination uptake (8, 33). Similar findings were reported in other settings, including Rwanda and Nigeria (24, 9). The importance of vaccine availability in utilization was further supported by the findings from the qualitative data where vaccines stock-outs was noted as a barrier. Ensuring a consistent supply of vaccines through improved vaccine supply chains and service delivery efficiency is therefore vital, particularly in low and middle-income countries where supply chain challenges are abound. In the current study, factors such as marital status, sex of the child, and place of delivery were not significantly associated with vaccine uptake. This aligns with findings from Burkina Faso Sweden, suggesting that healthcare access and parental attitudes may outweigh demographic characteristics in influencing vaccination decisions (24, 19). The non-significant association of these demographic factors in this study and the referenced studies may indicate that, in various contexts, other determinants like healthcare availability or parental beliefs are more influential in vaccination decisions. Despite the comprehensive approach taken in this study, several limitations should be acknowledged. First, the cross-sectional design limits the ability to establish causal relationships between the identified factors and measles immunization services utilization. Second, the reliance on self-reported data introduces the possibility of recall bias, especially regarding vaccination history and reasons for non-vaccination. To minimize recall bias, the study used vaccination cards, where available, in addition to the use of standardized questionnaires administered by trained data collectors to ensure consistency and accuracy in data collection. In addition, the study may have been limited by the unavailability of data on certain variables, such as detailed socioeconomic indicators or specific cultural practices. The above notwithstanding, the study also collected qualitative data which complemented the quantitative findings, providing a more comprehensive understanding of the factors influencing measles immunization utilization. Conclusion This study investigated the level of, and the factors influencing the utilization of measles immunization services among children under five years in Lira District, northern Uganda. The findings revealed a low measles immunisation utilization, with only 19.6% of children receiving the recommended two doses of measles vaccines. Key determinants of measles immunization services utilization were sociodemographic characteristics, education level, antenatal care (ANC) attendance, cultural beliefs regarding vaccination, socioeconomic barriers like high transport cost, and health facility-related factors such as vaccine availability. This underscores the need for actionable strategies to bridge the existing gap, including enhanced educational outreach and community engagement, strengthening antenatal care services, ensuring reliable vaccine supply, and strengthening the health system capacity, among others. Abbreviations aOR: Adjusted odd Ratio; CI: Confidence interval; COVID-19: Coronavirus Disease 2019; DHIS2: District Health Information Software 2; DHMIS: District Health Management Information System; HHs: Households; HMIS: District Health Management Information System; KIIs: Key Informant Interviews; LUREC: Lira University Research and Ethics Committee; NGOs: Non-governmental organizations; PPE: Personal Protective Equipment; SPSS: Statistical Package for the Social Sciences; UDHS: Uganda Demographic and Health Survey; VHTs: Village Health Teams; WHO: World Health Organization. Declarations Authors’ contributions RA wrote the research, developed the questionnaire, analyzed the data and wrote the paper and interpreting of the findings as well as joining on preparing the manuscript. MSO and RN supervised the protocol development, data collection, contributed to data analysis and interpretation of the findings, and contributed to the drafting and revising the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to acknowledge the staff of Faculty of Public health, Lira University for enabling a supportive environment. We are also indebted to the study team and the participants who made this study possible. Competing interests The authors declare that they have no competing interests. Availability of data and materials All data were presented in the manuscript. Consent for publication Not applicable. Funding Not applicable. References Abebe AM, Mengistu T, Mekuria AD. Measles case, immunization coverage and its determinant factors among 12–23 month children, in Bassona Worena Woreda, Amhara Region, Ethiopia, 2018. BMC Res Notes. 2019;12(1):71–71. https://doi.org/10.1186/s13104-019-4104-8 . Adedire EB, Ajayi I, Fawole OI, Ajumobi O, Kasasa S, Wasswa P, Nguku P. Immunisation coverage and its determinants among children aged 12–23 months in Atakumosa-west district, Osun State Nigeria: A cross-sectional study. 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Mobilize to vaccinate: Lessons learned from social mobilization for immunization in low and middle-income countries. Hum Vaccines Immunotherapeutics. 2020;16(5):1208–14. https://doi.org/10.1080/21645515.2019.1661206 . Kagabo DM, Kirk CM, Bakundukize B, Hedt-Gauthier BL, Gupta N, Hirschhorn LR, Ingabire WC, Rouleau D, Nkikabahizi F, Mugeni C. Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda. PLoS ONE. 2018;13(1):e0190739. Kagoné, M., Yé, M., Nébié, E., Sie, A., Schoeps, A., Becher, H., … Fisker, A. B. (2017).Vaccination coverage and factors associated with adherence to the vaccination schedule in young children of a rural area in Burkina Faso. Global Health Action, 10(1), 1399749. https://doi.org/10.1080/16549716.2017.1399749. Kaufman J, Tuckerman J, Bonner C, Durrheim DN, Costa D, Trevena L, Thomas S, Danchin M. (2021). Parent-level barriers to uptake of childhood vaccination: A global overview of systematic reviews. BMJ Global Health, 6(9), e006860. Ketema, D. B., Assemie, M. A., Alamneh, A. A., Alene, M., Chane, K. Y., Alamneh, Y.M., … Alebel, A. (2020). Full vaccination coverage among children aged 12–23 months in Ethiopia: A systematic review and meta-analysis. BMC Public Health, 20, 1–10. https://doi.org/10.1186/s12889-020-09412-9. Lakkis NA, Osman MH, Aoude LC, Hamadeh RR, Assi M. A multilevel analysis of factors associated with the uptake of measles-containing vaccines in eight-year-old children in Lebanon. Hum Vaccines Immunotherapeutics. 2021;17(5):1296–303. https://doi.org/10.1080/21645515.2020.1842802 . Larson, R. J., Jensen, J. L., Alvord, S. M., Sloan-Aagard, C., Skyles, T., Davis,S. C., … Poole, B. D. (2024). Effects of religious and cultural beliefs on vaccine attitudes in a Hispanic immigrant population in the United States. PLOS Global Public Health, 4(8), e0003519.. Manakongtreecheep K, Davis R. (2017). A review of measles control in Kenya, with focus on recent innovations. The Pan African Medical Journal, 27(Suppl 3) . https://doi.org/10.11604/pamj.supp.2017.27.3.11426 Larson Williams A, Mitrovich R, Mwananyanda L. Maternal vaccine knowledge in low-and middle-income countries—and why it matters. Hum vaccines immunotherapeutics. 2019;15(2):283–6. 10.1080/21645515.2018.1532241 . Mutua MK, Kimani-Murage E, Ettarh RR. (2011). Childhood vaccination in informal urban settlements in Nairobi, Kenya: Who gets vaccinated? BMC Public Health, 11 , 1–11. https://doi.org/10.1186/1471-2458-11-6 Nour TY, Farah AM, Ali OM, Osman MO, Aden MA, Abate KH. Predictors of immunization coverage among 12–23 month old children in Ethiopia: systematic review and meta-analysis. BMC Public Health. 2020;20:1–19. Omole, T. M., Sanni, F. O., Olaiya, P. A., Aturaka, O., Abdulsalam, M., Gwa, Z. T., … Njemanze, C. G. (2019). The challenges of Nigeria vaccine supply chain, a community of practice perspective. Int. J. Res. Sci. Innov, 6, 151–157.. Périères L, Séror V, Boyer S, Sokhna C, Peretti-Watel P. Reasons given for non-vaccination and under-vaccination of children and adolescents in sub-Saharan Africa: A systematic review. Hum Vaccines Immunotherapeutics. 2022;18(5):2076524. https://doi.org/10.1080/21645515.2022.2076524 . Reza HM, Das S, Sultana A. Determinants of child vaccination in Bangladesh: Factors associated with full immunisation coverage. EPRA Int J Multidisciplinary Res. 2019;5(4):193–200. https://doi.org/10.36713/epra2017 . Sarker AR, Akram R, Ali N, Sultana M. Coverage and factors associated with full immunisation among children aged 12–59 months in Bangladesh: Insights from the nationwide cross-sectional demographic and health survey. BMJ Open. 2019;9(7):e028020. Sheikh N, Sultana M, Ali N, Akram R, Mahumud RA, Asaduzzaman M, Sarker AR. Coverage, timeliness, and determinants of incomplete immunization in Bangladesh. Trop Med Infect Disease. 2018;3(3):72. https://doi.org/10.3390/tropicalmed3030072 . Soble A, Ko M, Gilchrist S, Malvolti S, Hasso-Agopsowicz M, Giersing B, Amorij J-P, Jarrahian C, El Sheikh F, Menozzi-Arnaud M, Scarna T. A review of potential use cases for measles-rubella, measles-mumps-rubella, and typhoid-conjugate vaccines presented on microarray patches. Vaccine. 2024;42(6):1230–46. https://doi.org/10.1016/j.vaccine.2023.12.047 . Ubosadmin. (2023, May 18). 2022 Statistical Abstract. Uganda Bureau of Statistics . https://www.ubos.org/2022-statistical-abstract/ Uddin MJ, Adhikary G, Ali MW, Ahmed S, Shamsuzzaman M, Odell C, Hashiguchi L, Lim SS, Alam N. Evaluation of impact of measles rubella campaign on vaccination coverage and routine immunization services in Bangladesh. BMC Infect Dis. 2016;16(1):411–411. https://doi.org/10.1186/s12879-016-1758-x . United Nations Children's Fund (UNICEF). (2022). UNICEF Data: Monitoring the Situation of Children and Women - Immunization. Available at: https://data.unicef.org/topic/child-health/immunization . Accessed January 10, 2023. World Health Organization (WHO). (2020). Immunization Agenda 2030: A Global Strategy to Leave No One Behind. Available at: https://www.who.int . Accessed January 10, 2023. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7302192","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498617827,"identity":"755b54a9-97b9-4933-9760-4d09c5e68c03","order_by":0,"name":"Romeo Atim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYLACxgYIdbChAkgxMzcQqYWNgeFgwxmQFkZStDS2IVmKC5i3dyc++LjDJo9fvvnBwZnzaqP524FaflRsw6lF5szZzYYzz6QVS7axGRzcuO147ozDjA2MPWdu49QiIZG7TZq37XDihmMMBgcfbjuW2wDUwszYhlfL9t8gLfuPsX84+HDOsdz5RGjZxgy2hY0H6LCGmtwNBLXwnN0sObMtrVjiWE7BwRnHDuRuBGo5iNcv7L0bP3xsA4ZY8/GND3tq6nLnnT988MGPCtxaYCABSh8GkwcIqkfSUkeM4lEwCkbBKBhhAAAx7GT3AHjufwAAAABJRU5ErkJggg==","orcid":"","institution":"Lira University","correspondingAuthor":true,"prefix":"","firstName":"Romeo","middleName":"","lastName":"Atim","suffix":""},{"id":498617829,"identity":"5f4d680c-0dcb-417e-8fc0-8659ee118085","order_by":1,"name":"Richard Nyeko","email":"","orcid":"","institution":"Lira University","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Nyeko","suffix":""},{"id":498617831,"identity":"028dd910-b679-4ab6-a13b-1294b3d62822","order_by":2,"name":"Marc Sam Opollo","email":"","orcid":"","institution":"Lira University","correspondingAuthor":false,"prefix":"","firstName":"Marc","middleName":"Sam","lastName":"Opollo","suffix":""}],"badges":[],"createdAt":"2025-08-05 15:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7302192/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7302192/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88895889,"identity":"e3285c2a-accf-491e-a6c0-eb5beffdbeba","added_by":"auto","created_at":"2025-08-12 13:04:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18371,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUtilization of Measles Immunization Services\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7302192/v1/f06030c9d6b0e076d9433cab.png"},{"id":88893527,"identity":"869ab795-7898-462f-94fe-cf329150cb29","added_by":"auto","created_at":"2025-08-12 12:56:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21168,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAge Distribution by Level of Utilization of Measles Immunization Services\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7302192/v1/2f8d2354158ff90f429ceffa.png"},{"id":88898391,"identity":"0fca2c05-4e24-46d7-8da2-88d8e585bb27","added_by":"auto","created_at":"2025-08-12 13:20:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":917134,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7302192/v1/65e31bdc-cede-4fb6-abfc-633accd5e2bf.pdf"},{"id":88893525,"identity":"152f7149-e039-4a5f-b794-b02142ea3c21","added_by":"auto","created_at":"2025-08-12 12:56:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27162,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7302192/v1/36279c5415e998a8d9736917.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utilization of measles immunization services among children under 5 years in Lira district, northern Uganda: a community-based cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eImmunization is one of the most effective public health interventions globally, significantly reducing childhood morbidity and mortality (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Among the vaccines, measles immunization plays a crucial role in preventing severe illness and death in children under five years. Measles is highly contagious and poses a significant threat in children with insufficient immunity. Despite global progress in measles control, with a 73% reduction in measles-related deaths from 2000 to 2019 (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), measles outbreaks remain a concern, particularly in regions with low immunization coverage.\u003c/p\u003e\u003cp\u003eSub-Saharan Africa continues to bear a disproportionate burden of measles cases and deaths, accounting for almost 60% of the global measles cases and three-quarter (74%) of measles-related deaths in 2019 (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Uganda, one such country, while has had progressive decrease in the under-five mortality rate to the current 43 deaths per 1,000 live births (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), vaccine-preventable diseases, including measles, among others, remain important causes of morbidity and mortality. Although the national measles immunization coverage stands at 83% (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), there persists great regional disparity \u0026ndash; being much lower in northern Uganda, including Lira district - exposing approximately 9,475 children under five in the district to measles-related risks (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The Uganda National Expanded Program on Immunization (UNEPI) aims to achieve high vaccination coverage, but challenges that lead to regional and local disparities persist.\u003c/p\u003e\u003cp\u003eSeveral general and context-specific factors, including demographic characteristics, infrastructure and healthcare accessibility, vaccine availability, socio-economic disparities, and cultural perceptions and beliefs, have been reported to influence immunization efforts (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The recent evidence indicating a decline in vaccination rates in Lira district in northern Uganda, from 69% in 2021 to 58% in 2023 (DHIS2, 2023) underscores the significance of context-specific factors and the need for a focused evaluation. This study therefore examined measles immunization utilization among children under five in Lira district to understanding the barriers and facilitators of utilization which is essential for designing targeted interventions to improve utilization.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design and setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis was a community-based cross-sectional study that employed both quantitative and qualitative approaches to data collection. The study was conducted in selected villages within two sub-counties (Agali and Ogur) in Lira district, northern Uganda, between June and July 2024. Lira district is located in northern Uganda and is part of the Lango sub-region, and has an estimated population of approximately 540,000 people, about 9.475 of which are children under five years of age (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The district has a mixed urban and rural composition, with the majority of residents engaged in subsistence farming and small-scale trade. Health services in Lira are provided through government health facilities, private clinics, and non-governmental organizations, although access remains a challenge due to infrastructure constraints and economic barriers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy population and sample size determination\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study population included children under five years in the selected villages in the two sub counties.\u003c/p\u003e\u003cp\u003eThe sample size for the quantitative data was estimated using Leslie Kish formula (1965) for single proportion, n = (Z\u003csub\u003eα/2\u003c/sub\u003e)\u003csup\u003e2\u003c/sup\u003e.pq/d\u003csup\u003e2\u003c/sup\u003e with a standard normal value corresponding to a 95% confidence interval (1.96), absolute errors between the estimated and true value of 5%, and an estimated proportion of measles vaccine utilization among children under 5 years of 59% (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The estimated sample size of 372 was adjusted for a design effect of 10%, giving a total of 409.\u003c/p\u003e\u003cp\u003eParticipants for the qualitative data included selected healthcare providers, opinion leaders and officials at the district health office. Determining the number of respondents for the qualitative data collection was based on the concept of data saturation. Data saturation was reached after nine respondents, with an additional two respondents being interviewed, giving a final sample size of 11 respondents.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003eChildren under 5 years in the selected villages of Agali and Ogur sub counties in Lira District.\u003c/p\u003e\u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Children whose caregivers declined consent were excluded from the study\u003c/p\u003e\u003cp\u003e\u003cb\u003eSampling and study procedures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe purposively selected Ogur and Agali sub counties in Erute county, Lira district, because of their reported poor utilization of immunization services (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). We then selected one parish from each of the selected sub counties using simple random sampling. All 18 villages in the selected parishes were studied. The Village Health Teams (VHTs) listed all the households (HHS) with children under 5 years in their respective villages in the selected parishes. Systematic random sampling was used to pick the HHs to be included in the study. The sampling interval was obtained by dividing the number of households by the sample size. The overall sample size for the study was 409 participants, distributed in a ratio of 1:1 for the two parishes. Given that each parish consisted of 9 villages, the average number of participants per village was calculated based on the specific household count of each village, which ranged from 70 to 90 households. We determined the starting point by throwing lot with numbers and we picked only one lot which was used as the starting point. We then sampled every fourth HHs until we got the required sample size. In cases where we didn\u0026rsquo;t find anybody at home, we attempted to come back twice before declaring them non-respondents.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection Tools\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe used a structured interviewer-administered questionnaire to collect quantitative data. This included sociodemographic characteristics (child and caregiver), socio-economic/cultural characteristics, child\u0026rsquo;s immunization, and health system related factors.\u003c/p\u003e\u003cp\u003eQualitative data was collected from the respondents using an in-depth interview guide, to provide insights into the contextual and cultural factors influencing immunization decisions. The questionnaires and interview guides were developed by the investigators in line with the study objectives. These were written in English as well as translated and administered in the local language (\u003cem\u003eLeb Lango\u003c/em\u003e) understood by the participants.\u003c/p\u003e\u003cp\u003eThe data collection tools were pretested to find out the suitability, ease of use, relevance of the questions, and any ambiguity so as to address the issues accordingly before the actual data collection was done.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy variables\u003c/b\u003e\u003c/p\u003e\u003cp\u003eUtilization of measles immunization services was the outcome variable, and the independent variables included sociodemographic characteristics, socio-economic / cultural characteristics, and health system factors. Utilization in this study was defined as receiving measles vaccination according to the recommended national or World Health Organization (WHO) immunization schedules. Measles vaccine utilization was measured as the proportion of children under 5 years who received the recommended doses of measles-containing vaccine (MCV1 and MCV2) based on their age, as per national vaccination guidelines.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Management and statistical analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuantitative data analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eQuantitative data was entered into an excel spreadsheet, cleaned, and exported to Statistical Package for Social Scientists (SPSS) (IBM) Statistics v23 for analysis. Descriptive statistics for categorical variables were presented as frequencies and percentages, while continuous variables were summarized as mean with standard deviation if normally distributed or median with interquartile range if non-normally distributed. The Chi-square test or Fischer\u0026rsquo;s exact test with Odds ratios and 95% confidence intervals were performed to determine the association between the predictor variables and utilization of measles immunization. The multivariate logistic regression model was used to assess the factors that were independently associated with utilization of measles immunization and reported by an adjusted odds ratio (aOR) at 95% confidence level. A two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered for statistical significance. Variables that were statistically significant at the bivariate level (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and those with p values\u0026thinsp;\u0026lt;\u0026thinsp;0.2 were included in the multivariate model.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQualitative data analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eQualitative data from the in-depth interviews were analyzed using manual thematic analysis to identify key themes and patterns. The analysis followed multiple stages. First, interview recordings were transcribed verbatim and reviewed for familiarization. Initial codes were generated by identifying key phrases, concepts and patterns in the data relevant to the research objectives. Related codes were then grouped into broader themes that reflected recurring ideas in the data, which were reviewed, refined, and clearly defined. Themes were developed inductively, emerging from the data rather than being predefined. The final themes were interpreted in relation to the research objectives. Findings from the qualitative analysis were triangulated with quantitative results to provide a comprehensive and holistic understanding of factors influencing measles immunization utilization in the study context. Results were presented as themes alongside the representative quotes from participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations and the study was conducted in accordance with the Declaration of Helsinki. The study was approved by Lira University Research and Ethics Committee (LUREC-2024-185). Voluntary informed consent was obtained from the parents/caretakers of the children before participating in the study after an explanation of the nature and purpose of the study, the potential benefits and risks.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eDescription of the study participants\u003c/h2\u003e\n\u003cp\u003eDuring the study period, a total of 402 responses were obtained from the caregivers of children under five years, resulting in a response rate of 98.3% (402/409). The median age of the children was 24 months (interquartile range [IQR]: 12\u0026ndash;36 months) and the majority were female, 291 (72.4%). A total of 393 (97.8%) of the children were delivered from the health facilities, and 394 (98.0%) had a child health card (simply understood by caregivers as an immunization card) available at the time of the survey (Table 1).\u003c/p\u003e\n\u003cp\u003eThe median age of caregivers was 30 years (IQR: 25\u0026ndash;35 years). Most of the primary caregivers were female, 287 (71.4%) and the biological mothers of the children, 272 (67.7%). A total of 143 (35.6%) caregivers had attained a primary level of education, 201 (50.1%) had post-primary education, and 58 (14.3%) had no formal education. Up to 283 (70.4%) of the biological mothers attended antenatal care during the pregnancy with the study child. The median parity of the female caregivers was three children (Table 1).\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eSocio-economic / cultural and Health Systems Characteristics\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eAbout a third of the caregivers, 119 (29.6 %) held cultural beliefs against immunization. Transportation costs was a concern to more than one-quarter, 114 (28.4%) of the caregivers, and bicycle was the primary mode of transportation for most respondents, 244 (60.4%). At least 89 (22.1%) of the respondents had experienced unavailability of vaccines during their visits at the health facilities for vaccination. A total of 146 (36.4%) of the respondents reported being denied vaccination services at least once when they visited the facilities on non-vaccination days, and over a third, 277 (68.9%) of the respondents had experienced delay in getting vaccination services at health facilities (Table 2).\u003c/p\u003e\n\u003ch2\u003eUtilization of Measles Vaccine among Children Under Five Years\u003c/h2\u003e\n\u003cp\u003eThe overall utilization of the measles vaccine among children under five years in our study population was 19.6% - 44 (11%) of whom were males and 35 (9%) were females (Figure 1).\u003c/p\u003e\n\u003cp\u003eConsidering the utilization of measles immunization services across different age groups, children within the age group of 25-36 months had the highest vaccination rate of 25.5%, followed by the 13-24 months age groups at 22.0% (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBivariate Analysis of Factors Affecting Measles Immunization Utilization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe factors significantly associated with measles immunization utilization on bivariate analysis included: Parity (\u0026chi;\u0026sup2; = 2.00, p = 0.0367), antenatal care (ANC) attendance (\u0026chi;\u0026sup2; = 7.18, p = 0.007), education level (primary) (\u0026chi;\u0026sup2; = 3.50, p = 0.321), cultural beliefs about immunization (\u0026chi;\u0026sup2; = 4.75, p = 0.029), transportation costs (\u0026chi;\u0026sup2; = 0.32, p = 0.570), and vaccine availability (\u0026chi;\u0026sup2; = 4.45, p = 0.035) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMultivariate Analysis for the Factors Associated with Utilization of Measles Immunization Services\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn multivariate analysis, children whose mothers attended antenatal care were 1.65 times likely to utilize measles immunization services compared to children whose mothers did not attend ANC (aOR 1.65; 95% CI 1.20-2.15, p= 0.002). Children whose caregivers had at least a primary level of education were 1.40 times likely to utilize measles immunization services compared to those whose caregivers had no formal education (aOR 1.40; 95% CI 1.05-1.85, p= 0.023). Children whose caregivers held negative cultural beliefs about immunization (aOR 0.55, 95% CI 0.40-0.76, p=0.002), had concern about transportation costs (aOR 0.60, 95% CI 0.45-0.80, p=0.010), and experienced denial of vaccination due to visiting the facility on a non-vaccination day (aOR 0.65, 95% CI 0.50-0.85, p=0.010) were less likely to utilize measles immunization services compared to their counterparts. Availability of vaccines was associated with a 1.40 times likely to utilize measles immunization services (aOR 1.40; 95% CI 1.05-1.85, p=0.020) (Table 4).\u003c/p\u003e\n\u003ch2 id=\"_Toc183982263\"\u003eQualitative Analysis results from the Key Informant Interviews (KIIs)\u003c/h2\u003e\n\u003cp\u003eThe qualitative component of this study aimed to explore the underlying factors affecting the utilization of measles immunization services among children under five in Lira district, northern Uganda. The analysis identified several themes that highlight the barriers and facilitators to immunization, revealing critical areas for intervention to improve utilization of measles vaccination. Five themes were identified that details the qualitative insights regarding measles vaccine utilization in the context of the study setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes Identified:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAwareness of measles vaccine importance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Key Informant Interviews (KIIs) revealed a widespread lack of awareness about the importance of measles vaccination among parents and guardians. Many respondents did not understand the severity of measles or the necessity of vaccination. This is exemplified by reports from two respondents below, which seems to support the finding of low measles vaccine immunization rates in the quantitative results.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Many parents do not understand the seriousness of measles and thus do not prioritize vaccination.\u0026rdquo; (A 30-year-old male respondent)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThere is generally low uptake of the measles vaccine in our community. \u0026ldquo;A 44-year-old facility in-charge\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural Beliefs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCultural misconceptions and traditional beliefs were identified as critical barriers to vaccination, supporting the findings from the quantitative data which showed that cultural beliefs against immunization negatively impact utilization of measles immunization services in the study setting. A common view from the respondents in the qualitative study was that some communities held beliefs that vaccinations were harmful and preferred traditional medicine over modern medical practices, as a community leader and a male teacher observed;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some communities believe that vaccinations are harmful and rely on traditional medicine instead.\u0026rdquo; (A 55-year-old male community leader)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Educational programs targeting parents and caregivers could help in changing the attitudes towards vaccination.\u0026rdquo; (A 29-year-old male teacher)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAccess to Immunization Services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeographical barriers and inadequate healthcare infrastructure were frequently mentioned by the respondents as major obstacles to accessing immunization services. The distance to health facilities and high transportation costs were important issues reported to affect many families, making it difficult to access and utilize measles immunization services in the study setting, as exemplified by a statement from a 45-year-old female respondent;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The distance to the health facility and high cost of transport are major issues for many families.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare System Issues\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrequent reports of vaccine stock-outs in the quantitative data were corroborated by the qualitative insights as important systemic issues within healthcare facilities that present significant barriers to consistent immunization utilization. This, coupled with the long waiting time at the health facilities to receive the immunization services are reported to demotivate some caregivers from seeking these services, as two of the respondents asserted thus;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We often face vaccine shortages, and long queues in the health facility which discourage the parents from coming for vaccinations.\u0026rdquo; (A 38-year-old female healthcare worker)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;\u0026hellip;a lack of trust in healthcare providers and the healthcare system overall is a barrier to vaccine acceptance and utilization by a number of caregiver.\u0026rdquo; (A 30-year-old female respondent)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe level of uptake in Ogur and Agali was quite low (19.6%). Key study findings on utilization of measles services were antenatal care attendance, education level, vaccine availability, transportation costs, and cultural beliefs.\u003c/p\u003e\n\u003cp\u003eThis study investigated the level of, and the factors influencing the utilization of measles immunization services among children under five years in Lira District, northern Uganda. The findings revealed a low measles immunisation utilization, with caregivers\u0026rsquo; education level, antenatal care (ANC) attendance, cultural beliefs regarding vaccination, socioeconomic barriers, and health facility-related factors, as key determinates.\u003c/p\u003e\n\u003ch2\u003eUtilization of measles vaccination\u003c/h2\u003e\n\u003cp\u003eOur study revealed a low level of utilization of measles immunization services in the study setting. Only about one in five children under five received the recommended doses of the measles vaccination. The level of measles immunization in the current study falls way short of the World Health Organization\u0026rsquo;s (WHO\u0026rsquo;s) target of 90% immunization utilization necessary for achieving herd immunity (43). The current finding aligns with that from other studies in similar low-resource settings. For instance, studies in Pakistan and Nigeria reported comparable results of \u0026nbsp;immunization levels of 44% and 32%, respectively (12, 3). Such similarities could be attributed to common barriers in low-resource contexts, including logistical challenges and systemic issues within health facilities. Low measles immunization utilization is a well-documented issue, often exacerbated by access, misinformation, and logistical challenges (30, 26) - highlighting the need for more effective outreach and education strategies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe discrepancy between possession of an immunization card-which was high, and utilization of measles vaccination, as found in the current study, is worth noting and deserves some attention. This phenomenon, which was similarly reported in a Kenyan study, reflects a lack of understanding and appreciation of the importance of immunization and the child health cards. This could, in addition, be attributed to the fact that in Uganda, the child health card - simply known to the caregivers and the broader community as \u0026ldquo;immunization card\u0026rdquo;, are also important and used for other purposes, including enrolment in school for pre-primary and primary levels - making it a necessity to have for this face value. This underscores the need for educational and community awareness interventions (20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAntenatal care (ANC) attendance emerged as a strong predictor of measles immunization utilization in this study, with a positive association between ANC attendance and the likelihood of a child being vaccinated against measles. As similarly reported in India (4), Bangladesh (15) and Sweden \u0026ndash; a high-income country (10), regular ANC visits are linked to enhanced health education, leading to increased vaccine uptake (4). Thus, the universal and crucial role of ANC as a platform for providing health education and raising awareness about the importance of immunization, and providing access to necessary resources, such as vaccination schedules, should be leveraged on as a targeted strategy to improve utilization of immunization services. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results from this study also highlights the impact of educational attainment on utilization of immunization services. Achieving at least a primary level of education increased the likelihood of utilizing measles immunization services. This finding accords with similar findings in Ethiopia and Nigeria, showing a positive relationship between caregivers\u0026rsquo; higher educational levels achievement and vaccination rates (16-17). Educated mothers are more likely to comprehend the importance of vaccination and adhere to immunization schedules, a notion supported by a finding from one systematic review and meta-analysis (18). As the qualitative data also highlighted, there is a clear need for enhanced educational campaigns to improve knowledge about the benefits of immunization among parents and caregivers in this and similar contexts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings also underscores the influence of culture on childhood immunization services. Strong negative cultural beliefs against immunization was a substantial barrier to utilizing measles immunization. This finding is of public health importance given its implication on the potential to drive vaccine hesitancy or refusal. The impact of culture transcends geographical and socioeconomic contexts, and is observed in low-and middle-income countries (31, 21). and developed countries alike\u0026nbsp;(19). This parallel suggests that cultural beliefs, whether rooted in local traditions or broader societal narratives, can similarly impact public health interventions globally, though often overlooked in most public health interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the socioeconomic front, high costs of transport to the health facility was a significant barrier to unitization of measles immunization services, underscoring the economic challenges associated with accessibility of healthcare. This finding echoes similar findings from studies\u0026nbsp;in Bangladesh, South Africa and Kenya (36, 8, 32)., which identified transportation costs as a major obstacle to healthcare access, including immunization services - just as also reported in China and Congo (22, 23). The qualitative data also highlighted geographical barriers and inadequate healthcare infrastructure, suggesting a need for improved access. This should include affordable transportation options, as well as bringing immunization services closer to communities through initiatives such as community outreaches and village-level immunization posts, among others.\u003c/p\u003e\n\u003cp\u003eThe availability of vaccines at health facilities was another significant determinant of measles vaccine utilization among the study population. Ensuring consistent vaccine availability increased the likelihood of utilizing measles vaccination services, reflecting similar findings from South Africa and Ethiopia where frequent vaccine stock-outs and logistical issues presented major barriers to vaccination uptake (8, 33). Similar findings were reported in other settings, including Rwanda and Nigeria (24, 9). The importance of vaccine availability in utilization was further supported by the findings from the qualitative data where vaccines stock-outs was noted as a barrier. Ensuring a consistent supply of vaccines through improved vaccine supply chains and service delivery efficiency is therefore vital, particularly in low and middle-income countries where supply chain challenges are abound.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the current study, factors such as marital status, sex of the child, and place of delivery were not significantly associated with vaccine uptake. This aligns with findings from Burkina Faso Sweden, suggesting that healthcare access and parental attitudes may outweigh demographic characteristics in influencing vaccination decisions (24, 19). The non-significant association of these demographic factors in this study and the referenced studies may indicate that, in various contexts, other determinants like healthcare availability or parental beliefs are more influential in vaccination decisions.\u003c/p\u003e\n\u003cp\u003eDespite the comprehensive approach taken in this study, several limitations should be acknowledged. First, the cross-sectional design limits the ability to establish causal relationships between the identified factors and measles immunization services utilization. Second, the reliance on self-reported data introduces the possibility of recall bias, especially regarding vaccination history and reasons for non-vaccination. To minimize recall bias, the study used vaccination cards, where available, in addition to the use of standardized questionnaires administered by trained data collectors to ensure consistency and accuracy in data collection. In addition, the study may have been limited by the unavailability of data on certain variables, such as detailed socioeconomic indicators or specific cultural practices. The above notwithstanding, the study also collected qualitative data which complemented the quantitative findings, providing a more comprehensive understanding of the factors influencing measles immunization utilization.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study investigated the level of, and the factors influencing the utilization of measles immunization services among children under five years in Lira District, northern Uganda. The findings revealed a low measles immunisation utilization, with only 19.6% of children receiving the recommended two doses of measles vaccines. Key determinants of measles immunization services utilization were sociodemographic characteristics, education level, antenatal care (ANC) attendance, cultural beliefs regarding vaccination, socioeconomic barriers like high transport cost, and health facility-related factors such as vaccine availability. This underscores the need for actionable strategies to bridge the existing gap, including enhanced educational outreach and community engagement, strengthening antenatal care services, ensuring reliable vaccine supply, and strengthening the health system capacity, among others.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eaOR: Adjusted odd Ratio; CI: Confidence interval; COVID-19: Coronavirus Disease 2019; DHIS2: District Health Information Software 2; DHMIS: District Health Management Information System; HHs: Households; HMIS: District Health Management Information System; KIIs: Key Informant Interviews; LUREC: Lira University Research and Ethics Committee; NGOs: Non-governmental organizations; PPE: Personal Protective Equipment; SPSS: Statistical Package for the Social Sciences; UDHS: Uganda Demographic and Health Survey; VHTs: Village Health Teams; WHO: World Health Organization.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRA wrote the research, developed the questionnaire, analyzed the data and wrote the paper and interpreting of the findings as well as joining on preparing the manuscript. MSO and RN supervised the protocol development, data collection, contributed to data analysis and interpretation of the findings, and contributed to the drafting and revising the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the staff of Faculty of Public health, Lira University for enabling a supportive environment. We are also indebted to the study team and the participants who made this study possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data were presented in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbebe AM, Mengistu T, Mekuria AD. Measles case, immunization coverage and its determinant factors among 12\u0026ndash;23 month children, in Bassona Worena Woreda, Amhara Region, Ethiopia, 2018. 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Immunization Agenda 2030: A Global Strategy to Leave No One Behind. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int\u003c/span\u003e\u003cspan address=\"https://www.who.int\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed January 10, 2023.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Utilization of Measles services, Measles vaccine doses, Immunization, Vaccination, Children, Unimmunized, Immunized and Lira District","lastPublishedDoi":"10.21203/rs.3.rs-7302192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7302192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMeasles remains a global health concern with high mortality rate, particularly in regions with low vaccine utilization, despite progress in measles control globally. In sub-Saharan Africa, first-dose measles vaccine utilization stands at 74%, well below the 95% target for herd immunity recommended by the World Health Organization (WHO). In northern Uganda, the proportion of children under five who receive the recommended doses of vaccines lags below the national average. This study therefore examined the level and factors influencing measles immunization utilization among children under five in Lira district, northern Uganda.\u003c/p\u003e\u003ch2\u003eMethodology\u003c/h2\u003e\u003cp\u003eThis was a community-based cross-sectional study in two sub counties in Lira district, northern Uganda that utilized both quantitative and qualitative methods of data collection. We surveyed 409 children under five, selected through systematic random sampling, Data were analyzed using SPSS for univariate, bivariate, and multivariate logistic regression. Qualitative data from in-depth interviews with healthcare providers, opinion leaders, and district health officials were analyzed using thematic analysis. Ethical approval was obtained from Lira University Research and Ethics Committee.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eMeasles vaccination completion was 19.6% (79/402). Factors that positively influenced utilization included antenatal (ANC) attendance (aOR\u0026thinsp;=\u0026thinsp;1.65, p\u0026thinsp;=\u0026thinsp;0.002), higher education level (aOR\u0026thinsp;=\u0026thinsp;1.40, p\u0026thinsp;=\u0026thinsp;0.023), and vaccine availability (aOR\u0026thinsp;=\u0026thinsp;1.40, p\u0026thinsp;=\u0026thinsp;0.020). Barriers included high transportation costs (aOR\u0026thinsp;=\u0026thinsp;0.60, p\u0026thinsp;=\u0026thinsp;0.010), cultural beliefs (aOR\u0026thinsp;=\u0026thinsp;0.55, p\u0026thinsp;=\u0026thinsp;0.006), and denial of vaccination on non-vaccination days (aOR\u0026thinsp;=\u0026thinsp;0.65, p\u0026thinsp;=\u0026thinsp;0.010). Qualitative findings highlighted vaccine shortages, cultural beliefs, and poor health facility access as barriers.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eMeasles vaccine utilization rate in the study setting of 19.6% was low. Antenatal care attendance, education level, vaccine availability, transportation costs, and cultural beliefs were key determinants of utilization. There is need develop and implement targeted strategies to address this gap, including community sensitization and health education, with emphasis of the benefits of childhood immunization in general.\u003c/p\u003e","manuscriptTitle":"Utilization of measles immunization services among children under 5 years in Lira district, northern Uganda: a community-based cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 12:56:46","doi":"10.21203/rs.3.rs-7302192/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a8bbb69-28f0-4e1c-9ca9-3e6697dfa7f4","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-12T12:56:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 12:56:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7302192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7302192","identity":"rs-7302192","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}