title: From the parents' perspective: a user-satisfaction survey of immunization services in Guatemala.
abstract: BACKGROUND
  Immunization coverage levels in Guatemala have increased over the last two decades, but national targets of ≥95% have yet to be reached. To determine factors related to undervaccination, Guatemala's National Immunization Program conducted a user-satisfaction survey of parents and guardians of children aged 0-5 years. Variables evaluated included parental immunization attitudes, preferences, and practices; the impact of immunization campaigns and marketing strategies; and factors inhibiting immunization.
  
  
  METHODS
  Based on administrative coverage levels and socio-demographic indicators in Guatemala's 22 geographical departments, five were designated as low-coverage and five as high-coverage areas. Overall, 1194 parents and guardians of children aged 0-5 years were interviewed in these 10 departments. We compared indicators between low- and high-coverage areas and identified risk factors associated with undervaccination.
  
  
  RESULTS
  Of the 1593 children studied, 29 (1.8%) were determined to be unvaccinated, 458 (28.8%) undervaccinated, and 1106 (69.4%) fully vaccinated. In low-coverage areas, children of less educated (no education: RR=1.49, p=0.01; primary or less: 1.39, p=0.009), older (aged>39 years: RR=1.31, p=0.05), and single (RR=1.32, p=0.03) parents were more likely to have incomplete vaccination schedules. Similarly, factors associated with undervaccination in high-coverage areas included the caregiver's lack of education (none: RR=1.72, p=0.0007; primary or less: RR=1.30, p=0.05) and single marital status (RR=1.36, p=0.03), as well as the child's birth order (second: RR=1.68, p=0.003). Although users generally approved of immunization services, problems in service quality were identified. According to participants, topics such as the risk of adverse events (47.4%) and next vaccination appointments (32.3%) were inconsistently communicated to parents. Additionally, 179 (15.0%) participants reported the inability to vaccinate their child on at least one occasion. Compared to high-coverage areas, participants in low-coverage areas reported poorer service, longer wait times, and greater distances to health centers. In high-coverage areas, participants reported less knowledge about the availability of services.
  
  
  CONCLUSIONS
  Generally, immunization barriers in Guatemala are related to problems in accessing and attaining high-quality immunization services rather than to a population that does not adequately value vaccination. We provide recommendations to aid the country in maintaining its achievements and addressing new challenges.
authors.forename: Lissette
authors.initials: L
authors.lastname: Barrera
authors.forename: Silas Pierson
authors.initials: SP
authors.lastname: Trumbo
authors.forename: Pamela
authors.initials: P
authors.lastname: Bravo-Alcántara
authors.affiliation: Comprehensive Family Immunization Project, Pan American Health Organization, 525 23rd Street NW, Washington, DC 20037, USA. velandiam@paho.org.
authors.forename: Martha
authors.initials: M
authors.lastname: Velandia-González
authors.forename: M Carolina
authors.initials: MC
authors.lastname: Danovaro-Holliday
mesh_terms: D000293:Adolescent; D000328:Adult; D002675:Child, Preschool; D005260:Female; D006166:Guatemala; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D017589:Immunization Programs / Q000706:statistics & numerical data*; D007115:Immunization Schedule; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010290:Parents; D017060:Patient Satisfaction; D012307:Risk Factors; D014611:Vaccination / Q000706:statistics & numerical data*; D055815:Young Adult