Another comes with his mother who’s seeking antenatal care and a third is brought to receive her first measles vaccine. All three are due for routine vaccinations, but all of them leave your health facility without receiving the doses they are due. These missed opportunities for vaccination or mov happen all too often and contribute to the under vaccination of children. Efforts to reduce mov can increase immunization coverage by making better use of existing sites and services as health workers and supervisors. It is important to recognize why these missed opportunities for vaccination happen so that you can identify the best interventions to address them. Remember a missed opportunity for vaccination refers to any time a person who is eligible for vaccination, visits a health facility but does not receive all the vaccine doses they are due. The person may be eligible for vaccination if they are unvaccinated, partially vaccinated or not up to date and free of contraindications to vaccination. There are proven strategies to reduce mov, but before you can determine the best interventions, the first step is to identify the reasons behind the mov. This can be done through a full mov assessment, which involves in depth field work, including interviews and focus group discussions with health workers and caregivers. However, you may already have sufficient evidence behind the reasons for mov in your health facilities. So you may want to move directly into implementation of interventions, or you may want to gather more data with small scale, health facility assessments, brainstorming workshops or by integrating mov questions into other assessments or reviews.

In this video we will review common reasons for mov. Many reasons fall into three main categories: health worker, behaviors, caregiver behaviors and health system issues. First, what are some ways that health workers contribute to missed opportunities for vaccination? Health workers may not screen an individual’s home base record to assess vaccination status during a routine or curative visit. Next, if an individual misses vaccinations, there may be confusion about their eligibility because of old policies with upper age limits for vaccination, health workers may think it is too late to give the missed vaccinations or that children of a certain age are no longer eligible. There may also be confusion regarding false contraindications health workers may think children cannot be vaccinated when they have a mild fever, cough diarrhea or other mild illness. Another common reason for a missed opportunity is concern about vaccine wastage. Health workers may be hesitant to open a multi dose vial for only one or a few children. When this happens, caregivers may have to wait longer or be told to come back another day next. What are some ways that caregiver behaviors might lead to missed opportunities? Caregivers may lose their child’s home based record or forget to bring it with them every time they visit the health facility. Caregivers may not know to ask to have children screened for vaccination each time they visit the facility or they may not know that their child is eligible for vaccination. Caregivers may decide not to ask about vaccination or may not want vaccination.

They may be confused about contraindications and not want their child to receive vaccines if they have a mild sickness. They may also be concerned about their child receiving multiple vaccinations at once or about potential adverse events. Finally, some missed opportunities for vaccination can occur due to health system issues. One of the key issues is a lack of integration between preventative and curative services or immunization, and non immunization staff. Non immunization staff who treat children are not trained to screen home based records and to provide or refer for vaccinations, and they may have little interaction with the immunization staff, because the treatment or clinical area is separate from the vaccination area. Another issue that leads to mov is stockouts or a shortage of vaccines and supplies. Another is when there are not enough home based records to make sure caregivers know what vaccines their children are due and for health workers to screen for eligibility. These shortages may be due to inadequate stock management practices or a lack of funding for supplies and transportation. Health systems can increase, missed opportunities for vaccination by limiting the hours or days that immunization or other services are available. For example, they may not have a policy regarding daily immunization services, or the hours of services may not be convenient for caregivers. Health systems may also promote having specific days for antigens that are in multi dose, vials, such as bcg and measles, in an effort to decrease wastage. So if someone comes on the wrong day, they will be turned away.

Another problem is delays or long queues at vaccination sessions, which may be due to staffing shortages or poor workflow organization. When caregivers have to wait a long time, some may leave before they receive the needed, vaccines and finally, poorly designed home based records can have a significant impact on vaccination. If they are damaged or difficult to read, they are not likely to be used effectively by either caregivers or health workers.