Healthcare workers here found during interviews that education about vaccines and interpersonal communication skills can increase patient information with informative recommendations to solve non-compliance vaccine parents, this view is consistent with other works (e.g. Turkey studied by Yalcin et al., 2022)[22]. Therefore, this can prevent the risk of an outbreak of vaccine-preventable disease in children under the age of five years associated with non-compliance with vaccination and low coverage - Sunampe.
Vaccination schedule
The results of the general data (Table 1) show that most of the children with an incomplete vaccination schedule (93.5%) have public health insurance. The acquisition of health services is therefore completely free. Contrary to what was found by Alker and colleagues (2020) [23], where around 96% of children under 5 years of age are insured, the overall figure falls to less than 92% for Latinos. However, it must be taken into account that the level of primary care in the US is higher, as it is more likely to work for the social objective, unlike in Peru, where there are more expenses due to illness and when more days of hospitalisation are needed (Muench et al., 2013) [24].
In the US, coverage for children has been found to be close to 96% since 2015, with most of the uninsured being of Latino origin (Alker, Kenney & Rosenbaum, 2020)[23]. In addition, in the United States, actors (doctors, nurses and providers) are working together to improve team-based care in a coordinated manner, seeking direct improvements for patients (Muench et al., 2013)[24]. On the other hand, in Sunampe-Peru, this study found that 93.5% of the mothers interviewed had public insurance (SIS or ESSALUD) and 89.4% had a partner (married or cohabiting). These figures in Peru are similar to those of Latinos in the US, but they are low given the level of primary health care and the fragility of the progress made in the face of the pandemic.
Unlike Tambo Mora, which is adjacent to Sunampe and has five health institutions serving a population of around 10,000, Sunampe has only one health facility (a clinic) that caters to a population of 30,000, including 2,500 children under the age of five. This means that young children cannot get vaccinated on time.
Administration of vaccines and timely
The data from Table 2 reveals that the administration of vaccines to the children in the study is highly inconsistent, suggesting that many did not receive timely vaccinations at the appropriate age. As per the immunisation strategy, only 57 out of 99 individuals received their SPR 1 vaccination. Hernandez et al. [2] observed similar outcomes in their study, with variations in vaccination rates and high dropout rates between the first and third doses. The authors estimated a national full schedule vaccination coverage of 48.9% [2].
On the other hand, Hoest et al. [21] discovered considerable discrepancies between the scheduled age for vaccination and the actual age at which children received the measles vaccine in their research. In fact, only 40% of children received the vaccine as planned, with specific delays noted [21]. According to a study conducted by Carhuavilca (2021) [25] in Peru, only 56.9% of children under one year of age regularly followed the vaccination schedule, with compliance being irregular at 46.1%. These results emphasize the need to devise strategies to enhance vaccination coverage and decrease existing gaps. Thus, ensuring adequate and timely protection for children, who are at risk of diseases preventable through vaccination, is crucial for maintaining public health. Additionally, the study conducted has contributed to improving critical areas, which were identified during the data comparison process. This was evident upon reviewing the primary documents. To confirm a child's vaccination status, refer to the medical records, vaccination card or online platform.
Appointment for the application of the vaccines
The findings from the survey regarding access to vaccines (Table 3) reveal that 91.06% of the mothers surveyed consider the waiting time for appointments to be lengthy. Additionally, 82.9% find it difficult to secure appointments for vaccine administration, while 95.1% believe that the number of health facilities available for vaccine application is insufficient. The prolonged waiting time is comparable to the findings of Ekhaguere et al. [26], who reported that the waiting time, including admission and discharge, ranged from 57 to 235 minutes. The duration depends significantly on the medical center. Additionally, they discovered that the vaccination administration procedures were complex [26]. Therefore, it is crucial to streamline administrative processes and provide the patient with prompt and efficient care. Therefore, ensuring adherence to the standard immunization protocol and avoiding missed opportunities is a common occurrence in many healthcare facilities. The Sunampe District, with only one vaccination centre serving a population of 2,500 children under the age of five, highlights the need for additional vaccination centres to be established. n points and reversing this problem that impairs compliance with optimal vaccination coverage.
Knowledge the importance of vaccinations
Despite the majority of mothers confirming their understanding of the importance of immunisation, 87.8% do not know the number of immunisations their child needs and 99.2% do not know the diseases against which immunisations protect. These findings align with those of Bangura and colleagues (2020) [27] in a systematic review, which identified a lack of vaccine knowledge among parents and/or caregivers as a barrier to immunization. On the other hand, a qualitative study conducted by Stephanie and her colleagues (2018) [28] found that despite the parents' limited knowledge about vaccine-preventable diseases, they deem vaccination crucial for themselves and their community. Similarly, a literature review conducted in Peru by Samame identified ignorance about vaccines as one of the leading reasons for non-compliance with the vaccination schedule among mothers of children under five years of age (Samame, 2019)[29]. Alternatively, Carhuavilca's (2021) study discovered a significant link between low vaccination rates and cultural considerations [25]. In turn, this highlights the critical role healthcare professionals play in achieving the national immunization strategy's objectives. As responsible parties, it is paramount to educate parents on the importance and purpose behind vaccinating their children. In addition to stressing the significance of adhering to the immunization programme to minimize contagion risk, it is highly probable that an outbreak of an immunizable disease could occur, given the low coverage achieved in recent years. Such an occurrence could have an impact on numerous children, not just in the Sunampe District, but across Peru.
A study conducted in China examined children aged 3 to 11 and their vaccine hesitancy towards COVID vaccines. It was discovered that parental reluctance to vaccinate was linked to lower health knowledge and was greater amongst mothers and parents with allergic children (Zhang et al., 2023)[30]. Our study, coupled with this finding, prompts further consideration regarding changes in parental attitudes due to the recent pandemic.
Reaction and compliance to the vaccines
Regarding the findings of Table 5 on adverse mental or allergic vaccine reactions, the majority of mothers (99.2%) expressed fear towards vaccinations. This fear is a limiting factor to complying with the vaccination schedule, as indicated by their lack of compliance despite acknowledging vaccines' importance in children's health. These findings align with those of Samame (2019) [29], who identified fear of negative reactions and perception of vaccines as a key reason for non-compliance with vaccinations. Additionally, there were documented cases of adverse events following influenza vaccine administration in 2010 and a child's death due to whooping cough in 2015 [29]. Additionally, Leon-Morillo and colleagues (2021) [31] have demonstrated a decrease in whooping cough cases among children up to one year of age during the pandemic in Spain, from 84 to 36. Similarly, Table 5 displays data from Peru that indicate a greater decrease from 272 to 60 children, which is consistent with our findings.
The connection between vaccinations and severe neuropsychiatric disorders is considered coincidental rather than causal and is regarded as an "urban myth” (Gasparini et al.,2015) [32]. This applies to the majority of vaccines, as the use of mercury-containing preservatives (e.g. thiomersal) has dwindled in recent years, thanks to the creation of new products that come in single-dose formats and do not necessitate preservatives, such as DPT vaccines. Approximately two decades ago, numerous companies in industrialised nations already made a decision to remove, lessen or substitute thiomersal in vaccines that are supplied in single dosages. Eliminating, reducing or replacing thiomersal in developing countries' vaccines is presently under deliberation, yet a conclusive decision has not yet been reached. This information is supported by Knezevic et al. (2004) and Dórea (2018) [33]-[34]. Low levels of neurotoxic substances may pose a risk for neurological disorders, as evidenced by data from large databases (Dórea, 2017) [35]. Mercury, among other neurotoxic agents, has been identified as a key risk factor for autism (Kalkbrenner et al., 2014) [36]. Additionally, approximately 40% of Peruvian children are at high risk for anemia, making it an important cofactor to consider. Although electroencephalograms have been proposed to study anemia projects in Perú (Mugruza-Vassallo, 2018) [37], Ica and Sunampe recently, no funding has been provided (Mugruza-Vassallo, 2023) [38].
Coverage achieved and mortality in the last five years
When analysing the coverage achieved over the past five years (see Table 6), it was found that 123 children had incomplete vaccinations, leaving a vaccination percentage of around 90%. In the worst case scenario, in 2017 this dropped to 23.94%, rising to 43.89% by 2021. A study conducted by Hernández and colleagues [2] in Mexico in 2020 revealed low vaccination rates, coupled with high dropout rates between the first and third doses administered. The estimated coverage of the complete vaccination scheme was 48.9%. The researchers have concluded that the available information is insufficient to accurately estimate the actual vaccination coverage. Furthermore, there are indications of overestimation of the coverage in the monthly reports, leading to a false sense of security. However, upon analyzing the coverage achieved in the Sunampe District over the past five years, more reliable data was obtained. It is clear that optimal vaccination coverage has not been achieved in any of the five assessed years, with 1-year-old children being the highest risk group. In 2020, this group only attained 43.17% coverage, a figure similar to that found in the province of Chincha, which was 47.59% in the same age bracket.
Analysing under-5 mortality remains an essential strategy for pinpointing correlated risk factors. For instance, Wolff and colleagues (2020)[39] recently reported that hospital death was more likely in younger patients. Additionally, the study showed that non-white, economically disadvantaged, and non-oncology diagnosed children were less likely to die at home compared to those who belonged to higher economic status, white, and oncology diagnosed patients. On the other hand, Xu and colleagues (2023)[18] conducted a study on changes in 1949 child deaths within a database of five years in China. In the SINADEF database, we studied data from children over a period of six years. Few cases of vaccine preventable disease occur each year in Sunampe, a small community in Peru.
The majority of cases are caused by factors other than vaccination. The SINADEF database was used to study data in children over a period of 6 years. Although most cases were not linked to vaccine preventable diseases, there were still a few cases reported annually in Sunampe, a small community in Peru. It is therefore feasible to explore other possible cofactors as identified in the SINADEF report. Our findings confirm the occurrence of preventable deaths in children in the Sunampe district.
Limitations: The accuracy of survey-based research methods relies on the proficiency and cooperation of parents in providing precise answers. An exchange of information has been conducted to enhance the significance of this study.
Wolff et al. (2020)[39] reported that younger ages correlated with increased likelihood of hospital death, while non-white or low-income children, as well as those with non-oncology diagnoses, were less likely to pass away at home compared to their counterparts who were white, had high incomes, or had oncology diagnoses. Income and oncology diagnoses were not explored in the present research.
Additionally, vaccine hesitancy was identified as a limitation due to concerns about adverse effects. An example is provided concerning the administration of various influenza vaccines at a health centre with a mostly randomized approach to immunoprevention. Wilkins et al. (2017) [40] determined that there were no significant incidents of serious adverse events associated with the use of new influenza vaccines when compared to control vaccines. However, a project proposal may assist in mitigating cognitive impairments [38]-[39]. It is also possible that a generic DPT vaccine will become available in the near future.