Health system and caregiver related factors influencing measles vaccination uptake: perspectives of Chadibe village, Botswana

Abstract

Background

Measles remain a significant public health concern, especially in Botswana, where sporadic and silent epidemics continue to challenge existing control measures. This study aimed to determine the health system and caregivers related factors influencing measles vaccine uptake.

Methods

A cross-sectional study was conducted between September and October 2024 in Chadibe village. The facility registers served as the data source and the study analyzed information from 201 under-fives records with a follow up caregivers questionnaire used to capture information on sociodemographic variables and health system related factors. Statistical analysis involved frequencies, bivariate and multivariate logistic regression.

Results

Our study revealed that 82.6% of children received first dose of measles vaccine, while 50.2% received the second dose. Both figures are lower than the WHO target. The key determinants related to two doses of measles vaccination include care giver characteristics and health system related. Caregivers aged 18–25 years (OR: 4.42; 95% C.I: 1.22-16.00, P = 0.023), 26–30 years (OR: 1.71; 95% C.I: 0.59–4.94) and 31–35 years of age (OR: 2.74; 95% C.I: 1.026–7.36) were more likely to get their children immunized. Care givers who walked to the health facility (OR: 2.28;95% CI:0.86-6.00), used public transport (OR:1.94; 95% CI 0.74–5.06) found vaccine to be always available (OR 12.8;95%CI: 2.24–73.92, P 0.004) sometimes available (OR 7.09;95% CI: 1.45–34.60, P0.01) were associated with the likelihood to have their children fully vaccinated. On multivariate analysis, caregivers who completed senior secondary education (AOR: 6.59; 95% CI: 1.02–7.36, P = 0.01), working full time (AOR = 1.77, 95% CI: 0.64–4.92) travelled less than 5 km to the health facility (AOR: 3.47;95% CI: 1.49–8.10, P = 0.004), received fairly good quality of service (AOR:2.20; 95% CI: 1.02–4.73, P = 0.043) had measles vaccine information (AOR = 3.97, CI = 1.455–10.85,P = 0.007) were also more likely to immunize their children.

Conclusion

The complete dose of measles vaccination rate in Chadibe is still low compared to the first dose of measles vaccination and global target. This study provides valuable insights into the epidemiology of the Measles vaccination. The low vaccination uptake highlights the urgency of raising awareness about vaccine importance and strengthening routine immunization programs.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-025-11966-4.

Introduction

Measles remains an important public health concern globally, despite the availability of an active vaccine [1, 2]. Worldwide, there were an estimated 10.3 million cases of measles in 2023, a 20% increase from 2022, according to new estimates from the World Health Organization (WHO) and the United States (U.S.) Centers for Disease Control and Prevention (CDC) [3]. Inadequate immunization coverage globally remains a major driver of the surge in cases. The WHO and CDC, estimates that, more than 22 million children missed their first dose of the measles vaccine in 2023 with an estimated 83% of children receiving their first dose of measles vaccine last year, while only 74% received the recommended second dose. Coverage of 95% or greater of two doses of measles vaccine is needed in each country and community to prevent outbreaks and protect populations from one of the world’s most contagious human viruses./reach heard immunity [3].

The number of measles infections are rising around the globe, endangering lives and health. As a result of global gaps in vaccination coverage, 57 countries experienced large or disruptive measles outbreaks in 2023, affecting all regions except the Americas, and representing a nearly 60% increase from 36 countries in the previous year [3]. The WHO African, Eastern Mediterranean, European, South-East Asia and Western Pacific regions experienced a substantial upsurge in cases. Nearly half of all large or disruptive outbreaks occurred in the African region [3].

Botswana, like many other countries, is still struggling to achieve heard immunity, with measles-containing vaccine 1 (MCV1) at 97% and measles-containing vaccine 2 (MCV2) at 79% [4]. Consequently, the first documented measles outbreak since 2010 occurred in January 2023 when the greater Francistown District Health Management Team (DHMT) detected 10 cases of measles in Chadibe village [5]. Although there were no recorded deaths with all the patients recovered. It was noted that none of the affected children had received the immunization and vaccination nor had an Under-Five card [5]. Despite efforts to increase vaccination uptake among them the measles-rubella campaign, challenges exist, and understanding the factors influencing measles vaccination uptake is essential for designing effective interventions. Therefore, the study objective was to determine the health system and caregivers related factors influencing measles vaccine uptake in Chadibe village with the view to propose strategies that the country can adopt to achieve total measles vaccine coverage as well as heard immunity.

Methods

Study design and setting

A quantitative cross-sectional descriptive study with an analytical component was conducted in Chadibe village in the greater Francistown district. Chadibe is situated west of Francistown, Botswana. The village’s population is 5,371 [6] approximately 25 km west of Francistown accessible via the A30 road.

Selection of study population

The study population included parents or legal caregivers/guardians of children under the age of five years, attending child welfare at a local clinic in their first 18 months of life. Care givers of children below the age of 18 months and those with incomplete data were excluded.

Sampling

The census method was used as our sampling technique for the study.

Data collection procedure

We examined 625 under 5 years Child welfare registers. Following exclusions, 201 participants included in the study were located using their address and contacts from the facility registers. A self-administered structured questionnaire was then utilized to gather data from the caregivers. See tools on supplementary material attached.

Variables measured

The questionnaire had two parts, the first part consisted of demographic questions like age, gender, marital status, educational level, employment status. Second part had vaccination status, access to immunization information, distance to the facility, mode of transport to facility, measles vaccine availability, quality of health care service questions.

Outcome measures

Full vaccination, (first dose and second dose).

Pretesting

The questionnaires were developed and translated into the native language being Setswana. The tools were pretested on 21 participants (10% of our total population) in a different clinic by well-trained research assistants. The principal investigator also checked data for completeness. This provided valuable insights into the feasibility, effectiveness, and potential challenges of implementing large-scale research and the tool was adjusted to improve its reliability and validity.

Measures to reduce selection and information bias

The study participants were selected using specific inclusion criteria for the study. Sampling bias was reduced by matching participants sampling frame to the target population.

Statistical analysis

Data was cleaned to reduce inconsistencies and analyzed using SPSS software version 30. Descriptive analysis was employed to describe characteristics of caregivers and health system related factors using frequencies, proportions, and numerical summary measures. The strength of the association between the predictor and outcome variables was assessed using bivariate and multivariate logistic regression. A crude and adjusted odds ratio (AOR) with a corresponding 95% confidence interval (CI) were computed and reported. Statistical significance was declared at p-value < 0.05.

Ethical approval

The study obtained ethical approval from the Botswana Health Research and Development Division dated September 25, 2024 (reference number: HPRD 6/14/1) before the study was conducted. Permission was obtained from each study site. The study has been planned according to the declaration of Helsinki (last updated; October 2013) which is as a statement of ethical principles for medical research involving human participants, including research using identifiable human material or data.

Informed consent

The consent form was read and signed by study participants who could read, and those who couldn’t were allowed to have a trusted relative or close friend to read and explain it to them while the investigator documented the procedure. The consent form included contact information for the researcher and the research ethics committees that approved the study as well as a full description of the study objective. The anonymity and confidentiality of the obtained data were always assured.

Results

Study population

Two hundred and forty-four care givers to under-fives attending child welfare services at Chadibe clinic between January 2024 to September 2024 were eligible for inclusion in the study. Forty-three were not reachable; therefore, only 201 participants were included in the analysis (Fig. 1). The survey response rate measured by dividing the total number of survey responses by the number of invitations sent to an audience (sample size) was 100%.

Fig. 1.

Study population

Socio-demographic profile of the participants

Among the age categories, 31–35 and 36 + aged care givers shared the highest number (n = 55, 27.4%) of children who received both first and second doses of measles each followed by a range of 26–30 with 54 (26.9%) fully vaccinated while 18% (n = 37) vaccinated children were cared for by care givers aged between 18 and 25. Females’ caregivers made up more than two third of the respondents (n = 140; 69.7%). On marital status, single caregivers made up the largest population (65.2%; n = 131) and divorced patients making up the smallest population (7,5%; n = 15). Care givers with senior secondary education also dominated the educational spectrum, accounting for 56.7% (n = 114) of the care givers followed by those with junior certificate (n = 51;25.4%) and primary education at 7.0% (n = 14). Similar numbers were seen across all employment status categories, with almost half of care givers (44%; n = 88.0) being unemployed followed by part time employed at 34.8% (n = 43) while the employed were the least with 21.4% (n = 43). More than half (n = 106) of the caregivers travelled less than 5 km to access health care facility, with walking being the most popular form of transportation (45.3%; n = 91) followed by those using public transport with 30.3%(n = 61) least being those who travelled using private vehicles at 24.4%(n = 49). On access to information, 81.1% reported to have had access to measles vaccine information. Measles vaccine was reported to be most of the time available by 69.2% (n = 139) with 30.3% reporting all time availability and 5.5%(n = 11) reporting rarely available. Fairly good quality of service by health care workers was reported by over half of the respondents (60.2%; n = 121), while 37% (n = 76) reported receiving poor quality service, excellent service was least common with 2.0% (n = 4). (Table 1)

Table 1.

Frequency table of socio-demographic profile of caregivers to children receiving child welfare services at Chadibe village

Variable	Category	Frequency	Percentage
Age	18–25	37	18.4
	26–30	54	26.9
	31–35	55	27.4
	36+	55	27.4
Gender	Male	61	30.3
	Female	140	69.7
Marital Status	Single	131	65.2
	Married	55	27.4
	Divorced	15	7.5
Education Level	PSLE	14	7
	JC	51	25.4
	BGCSE	114	56.7
	Tertiary	22	10.9
Occupation	Employed full time	43	21.4
	Employed part time	70	34.8
	Unemployed	88	43.8
Measles Information	Yes	163	81.1
	No	38	18.9
Distance to health facility	0–5 km	106	52.5
	> 5 km	95	47
Source Of Transport	Walking	91	45.3
	Public transportation	61	30.3
	Private vehicles	49	24.4
Availability Of Vaccine	Always available	51	25.4
	Mostly available	139	69.2
	Rarely available	11	5.5
Quality Of Services	Excellent	4	2
	Fairly Good	121	60.2
	Poor	76	37.8

Outcomes descriptive statistics

One hundred and sixty-six (82.6%) children received first dose of measles vaccine whereas one hundred and one (50.2%) received second dose making it a full dose of measles vaccine (Table 2).

Table 2.

Outcome descriptive characteristics

Variable	Vaccinated	Frequency	Percentage
1st Dose	Yes	166	82.6
	No	35	17.4
2nd Dose	Yes	101	50.2
	No	100	49.8

Factors associated with measles vaccination outcomes

The study carried out a bivariate and multivariable regression analysis to test the association of all the independent variables with measles vaccination. On bivariate analysis, we found that caregivers aged 18–25 years were 4.42 times significantly likely to immunize their child (OR: 4.42; 95% C.I: 1.22-16.00,P = 0.023), those aged 26–30 years (OR: 1.71; 95% C.I: 0.59–4.94) and 31–35 years of age (OR: 2.74; 95% C.I: 1.026–7.36) were also found to have an increased likelihood to immunize their children compared with the those more than 36 years of age. Care givers who walked to the health facility were found to be 2.28 likely to vaccinate their children (OR: 2.28;95% CI:0.86-6.00), while those who used public transport were 1.94 folds likely to have their children fully vaccinated (OR:1.94; 95% CI 0.74–5.06) compared to those who used private transport. Among those who reported vaccine to be always available at the facility (OR 12.8;95%CI: 2.24–73.92, P 0.004) and those who reported it to be sometimes available (OR 7.09;95% CI: 1.45–34.60, P0.01) were positively associated with the likelihood to have their children fully vaccinated. On marital status married caregivers (OR:1.2; 95% CI: 0.28–5.02) and single caregivers (OR:1.1; 95% CI: 0.29–4.75) were likely to have their children immunized. (Table 3)

Table 3.

Bivariate and multivariate logistic regression on factors associated with the measles full dose vaccination coverage among children attending child welfare clinic in Chadibe village

Variables	Categories	Full dose		Bivariate			Multivariate Analysis
		yes n(%)	No n(%)	OR	(95%CI)	P -Value	AOR	(95%CI)	P -Value
Age	18–25	14(13.8)	23(23.0)	4.42	1.22-16.00	0.023	0.22	0.06–0.81	0.226
	26–30	30(29.7)	24(24.0)	1.71	0.59–4.94	0.317	0.58	0.202–1.678	0.583
	31–35	26(25.7)	29(29)	2.74	1.026–7.36	0.044	0.36	0.136–0.974	0.364
	36+	31(30.7)	24(24.0)	-	-	-	-	-	-
Gender	Male	33(32.7)	28(28.0)	1.01	0.46–2.19	0.977	0.98	0.45–2.14	0.970
	Female	68(67.3)	72(72.0)	-	-	-	-	-	-
Marital status	Single	62(61.4)	69(69.0)	1.19	0.29–4.75	0.803	0.83	0.21–3.34	0.800
	Married	32(31.7)	23(23.0)	1.20	0.28–5.02	0.800	0.83	0.19–3.47	0.800
	Divorced	7(6.9)	8(8.0)	-	-	-	-	-	-
Educational level	Psle	3(2.9)	11(11.0)	0.95	0.16–5.66	0.962	1.04	0.17–6.18	0.960
	JC	21(20.8)	30(30.0)	0.42	0.11–1.63	0.215	2.33	0.61–8.88	0.210
	BGCSE	70(69.3)	44(44.0)	0.17	0.04–0.68	0.013	5.69	1.45–22.29	0.010
	Tertiary	7(6.9)	15(15.0)	-	-	-	-	-	-
Occupation	Fully Employed	30(29.7)	13(13.0)	0.56	0.20–1.55	0.268	1.77	0.64–4.92	0.260
	Part Time	37(36.6)	33(33.0)	0.97	0.42–2.24	0.957	1.02	0.44–2.34	0.950
	Unemployed	34(33.7)	54(54.0)	-	-	-	-	-	-
Distance to health facility	< 1KM	63(62.4)	43(43.0)	0.28	0.12–0.67	0.004	3.47	1.49–8.10	0.004
	> 5KM	38(37.6)	57(57.0)	-	-	-	-	-	-
Mode of transport	Walking	43(42.6)	48(48.0)	2.28	0.86-6.00	0.090	0.43	0.16–1.15	0.095
	Public Transport	25(24.8)	36(36.0)	1.94	0.74–5.06	0.170	0.51	0.19–1.33	0.173
	Private vehicle	33(32.7)	16(16.0)	-	-	-	-	-	-
Vaccine availability	Always available	25(24.8)	26(26.0)	12.80	2.24–73.92	0.004	0.07	0.01–0.44	0.004
	Sometimes available	69(68.3)	70(70.0)	7.09	1.45–34.60	0.015	0.14	0.02–0.68	0.015
	Never available	7(6.9)	4(4.0)	-	-	-	-	-	-
Quality of health service delivery	Excellent	4(3.9)	0(0.0)	8.00	0.000	0.990	-	-	-
	Fairly good	68(67.3)	53(53.0)	0.45	0.21–0.97	0.040	2.20	1.02–4.73	0.043
	Poor	29(28.7)	47(47.0)	-	-	-	-	-	-
Information on measles vaccine	Yes	92(91.1)	71(71.0)	0.25	0.09–0.68	0.252	3.97	1.455–10.85	0.007
	Never	9(8.9)	29(29.0)	-	-	-	-	-	-

On multivariate analysis, caregivers who completed senior secondary education were positively associated with the likelihood to immunize their children (AOR: 6.59; 95% CI: 1.02–7.36, P = 0.01), while those with junior secondary level education were 2.23 times likely to immunize their children (AOR:2.23; 95% CI: 0.61–8.88). Children whose caregivers were currently working full time were 1.77 folds likely to be vaccinated (AOR = 1.77, 95% CI: 0.64–4.92) than those with non-working care givers. Care givers who travelled less than 5 km to the health facility were positively associated with the likelihood to vaccinate their children (AOR: 3.47;95% CI: 1.49–8.10, P = 0.004) compared to those who travelled more than 5KM. Those who received fairly good quality of service from health care providers were also significantly more likely to vaccinate their children (AOR:2.20; 95% CI: 1.02–4.73, P = 0.043) compared to those who received poor quality service. On access to information, care givers who had measles vaccine information (AOR = 3.97, CI = 1.455–10.85, P = 0.007) were more likely to vaccinate their children than those with no access to information. (Table 3)

Discussion

Our findings indicate that measles vaccine coverage in Chadibe clinic is below the herd immunity target (95%). The measles vaccination rate has historically been low in developing countries [7], which is relatable to our study. Our study showed an increased odds of children full measles vaccination for mothers aged 18–35 years compared with those above 36 years of age, this concurs with a study [8] showing that, up to date vaccine coverage was significantly associated with maternal age. Coverage increased as maternal age increased, coverage among children with 17-year-old mothers was 64%; coverage among children of mothers 17–26 years old increased by 16.3% overall (approximately 1.8% per year). After 26 years of age, coverage did not increase significantly as maternal age increased [8].

Caregivers who had primary education and above were found to have increased odds to have their children fully vaccinated for measles. This is consistent with previous studies showing that having primary school maternal education and above is correlated with higher likelihood of completing childhood vaccination thus suggest that as maternal education status increases, the likelihood of their children being fully vaccinated also increases [1, 9, 10]. A possible explanation is that a higher level of education may enhance a mother’s understanding of the importance of routine immunization for their children. Conversely our study is in contrast to a National Family Health Survey conducted in India revealing that Mothers with lower levels of education showed an increased odd of having zero-dose measles children [1].

Distance to the health facility is a significant barrier to vaccine take-up, regardless of the type of vaccine. Our study also showed that children staying within a 5-kilometer (KM) radius had increased odds of being immunized compared with those furthest. This is in agreement with a study in Malawi indicating that proximity to a vaccine-providing health facility among rural children can be considered a proxy for remote ruralness thus those who are far from a vaccine-providing facility are likely to be far from a population center and far from services more generally and children likely inequitably under-vaccinated [11]. Moreover, This is supported by findings from existing studies showing that access to nearby health facilities is particularly crucial in rural and remote areas, where reaching the distant health facility could be challenging [9, 12]. A possible explanation could be that access to population living within 5 km of a public health facility, may be less of a barrier to vaccination uptake than in areas where health facilities may be farther away [13]. Caregivers who perceived vaccine availability all time and sometimes had increased odds of having their children fully vaccinated, this concurs with community-based cross-sectional study conducted in Sudan which found that perceived accessibility and availability of measles vaccine was associated with measles vaccine uptake, as those who strongly disagreed, disagreed, or were unsure were more likely to partially or not to vaccinate their children [14].

The present study found that caregivers perceiving the care received as being of fairly good quality generally had increased the odds of getting their children immunized. This is consistent with a cross sectional survey conducted in 14 countries (Four low-income or lower-middle-income countries, five upper-middle income countries, and five high-income countries) on health system quality and COVID-19 vaccination which indicated that having a regular and high-quality provider, and receiving other preventive health services were positively associated with vaccination and that confidence in the health system and government also increased the odds of vaccination [15]. Access to vaccine information was found to increase the chances of vaccine uptake compared to those who do not have information. This concurs with a cross-sectional epidemiological study conducted in Pakistan showing that a lack of awareness about vaccination benefits and misinformation about vaccines among the public are barriers to vaccination uptake [2].This is further corroborated by a study in Bangladesh showing that access to information and exposure to mass media has been observed to be positively associated with vaccination of children and better child health care seeking [16]. This can be explained that access to information through the media is essential to increase one’s understandings and awareness of what takes place in the surroundings [16].

Strengths and limitations of the study

The study’s results may be applicable to other regions with comparable socioeconomic and cultural characteristics. However, despite considerable diligence, to assure the study integrity, the study’s conclusions may be influenced by several limitations. Due to the retrospective nature of the study, it is difficult to determine the accuracy of information gained through individuals’ recall. Furthermore, as a cross-sectional study, causal relationships could not be established due to the lack of temporal connection. To mitigate this bias, we employed standardized questionnaires to ensure consistent data collection across all participants. We also verified or cross-validated information provided by participants with data from registers and cards to minimize bias and enhance accuracy.

Conclusion

The study underscores the urgency of addressing last-mile measles vaccination gaps in Botswana. Achieving measles elimination requires sustained efforts and strengthening demand for routine immunization through enhanced community engagement strategies. This study also highlights the need for enhanced surveillance and control efforts in response to the ongoing burden of measles in the region to ensure that children are reached. Targeted interventions informed by study results can enhance immunization coverage therefore, the study results have the potential to contribute to informed decision-making, supporting Botswana’s roadmap for the measles and rubella elimination goal.

Recommendation

We recommend additional research utilizing a qualitative study designs. This will provide in-depth explanations of the quantitative results enabling researchers to delve deeper into the “why” and “how” behind the current quantitative study results, potentially identifying new variables or clarifying existing relationships behind measles vaccine uptake thus providing richer context and helping to understand the nuances of the quantitative results.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted odds ratio

CDC

Centers for Disease Control and Prevention

CI

Confidence interval

DHMT

District Health Management Team

MCV1

Measles-containing vaccine 1

MCV2

Measles-containing vaccine 2

WHO

World Health Organization

Author contributions

G. A. S. was responsible for study conceptualization; data curation; investigation; methodology; project administration; resources development, analyzed and interpreted the data. writing original draft; writing review & editing. A. D, M. O. T, K. D, N. T. K. L.B contributed to conceptualization, project administration; resources development.KM contributed to manuscript writing review and editing.

Funding

This research did not receive any funding, it was financed from out of pocket.

Data availability

Data available within the article or its supplementary materials.

Declarations

Ethical approval and consent to participate

The study obtained ethical approval from the Botswana Health Research and Development Division dated September 25, 2024 (reference number: HPRD 6/14/1) before the study was conducted. Permission was obtained from each study site. The study has been planned according to the declaration of Helsinki (last updated; October 2013) which is as a statement of ethical principles for medical research involving human participants, including research using identifiable human material or data.

Consent for publication

Written informed consent was obtained from all participants before their inclusion in the study. We also ensured the highest level of confidentiality and anonymity of the collected data.

Competing interests

The authors declare no competing interests.