Reaching zero-dose and under-immunised children in East New Britain, Papua New Guinea: formative data collection study results

Immunisation is a life-saving public health intervention, but routine immunisation coverage varies substantially across Papua New Guinea. This study aimed to:

• identify children in East New Britain province who have never been immunised, or who have missed some of their routine immunisations
• analyse the barriers to and enablers of achieving widespread immunisation coverage
• strengthen service delivery and community uptake of routine immunisation in areas with significant numbers of under-immunised children.

Analyses using routine surveillance data shared by East New Britain Provincial Health Authority highlighted that immunisation coverage varies widely across the province, with coverage declining in most local-level government (LLG) areas over the past five years. Across the province in 2021, 72% of children under one year received the first dose of the Pentavalent vaccine (Pentavalent-1), while only 54% of children received the first dose of Measles-Rubella (MR-1) vaccine. 

It was estimated that there were approximately 3270 and 5446 children under one year of age across East New Britain in 2021 who had not received Pentavalent-1 or MR-1 vaccines respectively. Dropout between Pentavalent-1 and MR-1 was 26% (Section 1). Unvaccinated children were more likely to reside in Gazelle or Rabaul districts. With the guidance of East New Britain Provincial Health Authority, sites to target for data collection to better understand barriers to routine immunisation and future program implementation were identified in five LLGs. This included Kokopo Urban district to ensure representation from a predominantly urban area, and Duke of York Islands, to understand barriers to immunisation in remote island regions.

In contrast to surveillance data, structured interviews with 237 parents and caregivers in these target areas revealed that 98% self-reported their child had received at least one vaccine, and all believed that vaccination was important (Section 3). This indicates that further efforts to identify and reach caregivers who do not engage with routine immunisation services in East New Britain may be needed to gain a more holistic understanding of reasons why children are not immunised. However, service satisfaction and trust in healthcare workers varied across the target areas, suggesting that the challenges faced may differ by location.

Structured interviews were also undertaken with 30 healthcare workers (Section 3). While most had more than 10 years’ work experience, not all staff had received recent immunisation training. Additionally, knowledge of some vaccines was lacking, and there was variability with regards to recording immunisation data in the health facility registers. Further efforts should engage healthcare workers in opportunities to strengthen skills and knowledge to enable them to better communicate with and support their communities. 

In-depth interviews with 33 caregivers and 28 healthcare workers provided further insights into the barriers and enablers identified by the structured interviews. Quotes from these interviews are included throughout this report to add additional context to some of the quantitative findings.

Qualitative data were also collected through focus group discussions with 53 community and religious leaders (Section 4). There were some notable differences between the five LLGs but generally, community leaders raised the importance of community level healthcare through aid posts, flagged the significance of traditional medicine in some communities, and wanted to be more involved in advocating and creating awareness about immunisations in their communities.

Health facility assessments at nine facilities across Gazelle and Kokopo districts representing a wide range of service providers highlighted issues with vaccine stock-outs, availability of cold chain infrastructure, and incomplete electronic health record management (Section 2). 

Overall, the two biggest barriers to routine immunisation identified through this formative research were:

1. Inadequate community knowledge, understanding, and awareness of vaccines and schedules.
2. Healthcare workers report have insufficient training, especially around communication, to support their communities and advocate for routine immunisation.

Strategies to address these barriers are multi-faceted. Section 5 describes in more detail some potential activities that can be tailored to specific areas to increase immunisation coverage in East New Britain and improve health outcomes for all. These strategies were co-designed with East New Britain Provincial Health Authority, in consultation with other key partners and local organisations working at the community level to respond to health needs. Over the next two years, these strategies will be implemented and evaluated to determine their impact, and recommendations for future policy, health service, and program delivery will be developed.  

Suggested citation

Burnet Institute. Reaching Zero-Dose and Under-Immunised Children in East New Britain, Papua New Guinea: Formative Data Collection Study Results. Melbourne: Burnet Institute; 2023.

Author contact details

Contact Ms Milena Dalton, Senior Research Fellow, Burnet Institute at milena.dalton@burnet.edu.au.

Contact Dr Stefanie Vaccher, Senior Research Fellow, Burnet Institute at stefanie.vaccher@burnet.edu.au.