Using behavioral science to understand under-vaccination in Kathmandu

Getting every child access to immunisation requires an up-close, specific, and contextual look at the real-world hurdles facing families. In Nepal’s capital, a team of researchers mapped out the barriers

  • 23 November 2022
  • 6 min read
  • by Nicole Castle ,   Prajita Mali ,   Swechhya Shrestha ,   John Snow, Inc
A baby getting vaccinated in Nepal. Credit: © UNICEF and U.S. CDC/ UN0666532/Laxmi Prasad Ngakhushi
A baby getting vaccinated in Nepal. Credit: © UNICEF and U.S. CDC/ UN0666532/Laxmi Prasad Ngakhushi


Meet Chameli

Chameli* moved to Kathmandu a year ago with her husband and five children. Married at age 12, Chameli is now 23 years old and pregnant with her sixth baby. Chameli leaves for her job in a factory at 10am and only returns at 8pm.

Despite wanting the best for her children, she has faced many challenges in getting them fully vaccinated. Before moving to Kathmandu, she lived with her father-in-law in a small village. He did not allow her to immunise her children. Chameli decided to secretly vaccinate her children.

Bringing together caregivers, community leaders, and health workers helped challenge assumptions about who was not fully vaccinating their children, and why.

However, she did not have a good experience: health workers did not allow her children to play with the toys in the centre, and gave her limited information about the vaccines and potential side effects. And, because she was hiding her visit to the health care centre from her father-in-law, she didn't keep a record of which vaccinations and how many doses her children had received.

After the family moved to Kathmandu, Chameli's husband returned to his village, leaving her alone in the city with the children and without support. She was unable to complete her youngest child's vaccination schedule because she did not know where the vaccination centre was in Kathmandu.

And even if she had known, Chameli would not have had the time or money to bring her children for vaccination during service hours, or to care for them if they fell sick.

Unfortunately, Chameli's story is not unique. Although immunisation is considered one of the most successful programms in Nepal, DTP3 vaccination coverage has stalled, falling from 93% to 84% between 2019 and 2020, bouncing back only modestly to 91% in 2021. That coverage rate likely still does not take into account all of the effects of the COVID-19 pandemic, which has contributed to the largest continued backslide in vaccination in 30 years.

With an estimated 50,000 zero-dose children in the country and a renewed focus on equity in access to vaccination services, it is critical to understand the behavioural and social drivers that affect vaccine uptake among under-immunised and zero-dose communities.

Understanding under-vaccination in Kathmandu

To better understand those dynamics in Kathmandu Metropolitan City, a team from the Behavioral Science Center, led by Kathmandu University School of Medical Sciences with support from JSI and UNICEF Nepal, conducted a rapid inquiry using adapted Behavioural and Social Drivers (BeSD) of vaccination tools. The team interviewed caregivers of children under two, and health workers, including female community health volunteers (FCHV).

Low-income and migrant families in particular faced several challenges, the researchers found. Often, they lacked knowledge about vaccination services, frequently also encountering a lack of availability of those services. Female caregivers in these social groups tended to lack decision-making power, leaving them simultaneously responsible for childcare but unable to decide if, or when, to take their children for vaccination.

Families also balanced competing priorities. If, for instance, vaccination services were only offered between 10:00 and 13:00, was it worth losing a day's wages to make sure a child received his or her shots? For many parents, previous negative experiences of health services acted as an additional barrier.

Journey mapping

With findings from the rapid inquiry in hand, the research team brought together ward officials, health workers, FCHVs, and caregivers to validate and identify additional insights.

The meeting began with Chameli's story. Meeting participants then mapped Chameli's user journey using a tool developed by UNICEF and the WHO called the Journey to Health and Immunization – a person-centred guiding framework that considers supply- and demand-side barriers and enablers along one's journey to vaccination.

One of the journey to health and immunisation maps. Credit: JSIi
One of the Journey to health and immunisation maps.
Credit: JSIi

Bringing together caregivers, community leaders, and health workers helped challenge both health workers' and government leaders' assumptions about who was not fully vaccinating their children, and why. All participants were able to identify new challenges and enablers for caregivers and the health workers that provide vaccination.

The exercise prompted broader discussion on everyone's roles in reaching under-immunised and zero-dose communities with vaccination services, from the caregiver, to the FCHV, to the health worker at the facility, to municipal leadership. Moreover, the mapping process provided space for all perspectives to be shared and to take a systems approach to understanding vaccination-seeking behaviour, as structural, environmental, and social determinants all shape behaviour.

Solutions by the community for the community

Collaborating with the community in this process was essential to generating ideas to overcome barriers related to vaccination. The solutions that the group prioritised were:

  1. Mobilise FCHVs to identify migrant households that are often missed by routine vaccination and primary health care services. Mapping these households will enable FCHVs to visit them to share important health information, including the time and location of essential services. The research team's findings showed that FCHVs did not know where these households were.
  2. Advocate for changes to shift work for health workers. Changes to work schedules can help limit health worker burnout and offer vaccination services at more convenient hours. In Nepal, working hours are currently set to 10:00 to 17:00. This time is monitored and health workers are not compensated for additional work. Advocating for changes to shift work could create an environment that enables health workers to adopt flexible service hours to meet the community's needs, without requiring them to work extra hours or be disciplined for not clocking in and out during set hours.
  3. Include user stories in interpersonal communication training. Using stories can help increase empathy among health workers and offer training scenarios that reflect the challenges and conversations they may face in their communities. Regular follow-up training to support health workers' skill development not only helps the health workers, but can improve the community's immunisation service experience.

Participants discuss and map the user journey to immunisation.Credit: JSI
Participants discuss and map the user Journey to immunisation.
Credit: JSI

Ideating with participants led to the identification of practical, feasible solutions that could help improve routine immunisation services in ways that reflected community and health worker needs. The ward representatives that participated even committed to providing financial resources to the solutions prioritised.

This process demonstrated the value of behavioural insights in understanding the specific, contextual challenges to providing equitable vaccination services and engaging communities to co-create solutions to those challenges.

After participating in the process, FCHVs from the community were motivated to follow up with caregivers including Chameli, to encourage them to vaccinate their children and to better understand the challenges they face. As Chameli's delivery date approaches, FCHVs and other health workers are ready to support her to vaccinate all six of her children.

*Chameli's name was changed for the purpose of the exercise, and of this story.

About the authors

Nicole Castle, JSI, Behavior Initiative

Prajita Mali, Kathmandu University School of Medical Sciences

Swechhya Shrestha, UNICEF Nepal

Thank you to the Kathmandu University School of Medical Sciences research team, Behavioral Science Center, and UNICEF Nepal for contributing to this research and materials shared in this blog.