"The main reasons for low vaccination rates in urban Dili included caregivers' knowledge, attitudes, and perceptions as well as barriers at immunization service sites."

The objective of this study, conducted in the Democratic Republic of Timor-Leste, was to identify the key factors that contribute to low immunisation coverage in urban Dili, the capital city. "The findings were intended to help ...to devise effective and feasible solutions that would improve immunization services, reduce dropout rates, and increase coverage. The study sought to:

• Determine deficiencies/insufficiencies within the health services that contribute to sub-optimal vaccination coverage
• Better understand parents' knowledge, attitudes, and practices regarding vaccinations and the health system and how these may contribute to sub-optimal vaccination coverage
• Recommend modifications to service availability, provider practices, community mobilization, and/or health promotion that could improve vaccination coverage."

Methods included: a cross-sectional, mixed-methodology of combined qualitative (primarily) and quantitative methods, including observations, exit interviews, in-depth interviews, and focus group discussions, including interviews with health staff members (11 vaccinators and 7 health facility directors) and community leaders. Family members of children ages 6 to 23 months participated in focus group discussions. Observations (recorded on structured checklists) focused on characteristics of caregivers, types of antigens offered, potential missed opportunities, and health workers' manner, counseling, and vaccination technique. A semi-structured questionnaire was used in exit interviews to learn 1) the caregivers' perspectives on communication and their interactions with health care workers and 2) the client experience of: waiting time, level of client satisfaction, what immunisations the child received, providers' communication and behaviour toward clients, reasons for bringing the child, the return date for the next vaccination, and understanding of possible adverse events following immunisation. In-depth interviews included health staff and community leaders.

Data was analysed for: family socio-demographics; caregivers' knowledge and attitudes; health workers' views, attitudes, and practices; service provision; and health information and education. The study results indicate that "poor immunization coverage in Dili is related to multiple, complex, and interrelated factors, including inconsistent and irregular immunization sessions, lack of adequate outreach activities, and some health care workers' poor behavior toward clients, which leads mothers to fear being reprimanded....[C]aregivers' negative experiences at vaccination sites or with post-immunization side effects were among the most common factors that discouraged immunization." Limited availability and irregular hours of services contributed to low numbers of fully immunised children.

Recommendation include:

• Expanded Programme on Immunization (EPI) service hours should be extended and more outreach sessions be held at schools, through night clinics, and after church on Sundays or at other times. Outreach efforts could integrate other maternal and child services as well. "The MOH [Ministry of Health] needs to ensure an uninterrupted supply of vaccines and associated supplies around the year. Currently, health services do little to promote vaccination or to engage with community leaders and networks."
• The MOH can improve health care workers' attitudes and practices toward clients and to expand mobilisation activities, requiring "a combination of training, including sensitization aimed at changing attitudes, supportive supervision, steps to reduce the flood of clients at certain times of the day, and adding additional staff. Improved health care worker communication can help caregivers understand what vaccinations their child has received and should receive in the future, and can reduce anxiety about side effects."
• In terms of structuring EPI improvements, "[m]icroplanning at the sub-district level should be organized regularly and include community leaders, health care workers, volunteers, and civil society organizations. The national and district immunization programs need to support Dili's sub-districts in communicating better about vaccination - their importance, safety, and the basic schedule."