ORGANIZATIONAL ASPECTS AND A SCHEDULE FOR ACCESS TO VACCINATION FROM USERS’ PERSPECTIVE

Objective: to understand access to vaccination and its organizational aspects in the daily routine of Primary Health Care from users’s point of view. Method: a holistic-qualitative multiple case study based on Comprehensive Sociology of Everyday Life, with 74 users from four sanitary microregions of the West Minas Gerais Extended Health Region, Brazil. As evidence data sources, we used the open and intensive individual interview, guided by a semi-structured script and technical visit to the vaccine rooms. Data were collected between June 2016 and April 2017. Data analysis was based on thematic content analysis. Results: proved to be obstacles that compromise access to immunization services such as: the establishment of specific days for the performance of certain vaccines; the opening hours of vaccine rooms; lack of immunobiological; lack of guidance on the part of health professionals. It was evidenced that direct contact and insertion of users in other actions and services of the unit favor access to vaccination. A schedule for better access was suggested by users, who recommended: the reorganization of the days and times available for vaccination; vaccine card computerization; implementation of dissemination strategies to expand search for immunization; vaccination room structural adequacy; expansion of human resources in health units. Conclusion: it is emphasized the importance of services their and adopting strategies that enable user-centered care, promoting access to health services and, consequently, immunization.


INTRODUCTION
Immunization is a proven action to control and eliminate infectious diseases. It is estimated that more than 30 doses of vaccine are administered globally every second and no other health intervention reaches so many people or is able to prevent such a varied range of public health problems. 1 Within the Scope of the Unified Health System (SUS -Sistema Único de Saúde), immunization services are strategically inserted in the routine actions of Primary Health Care units (PHC). In recent years, it is a fact that routine vaccination, as well as specific epidemiological surveillance actions, have been shown to be effective in the control, elimination and eradication of immunopreventable diseases. 2 However, challenges still remain to be overcome. Among these challenges, we highlight the achievement of vaccination coverage goals and their homogeneity in all Brazilian cities. A study that aimed to describe the risk classification of immunopreventable diseases in Brazilian municipalities, based on indicators of vaccination coverage, showed that several municipalities did not achieve adequate coverage. Other municipalities presented a high proportion of abandonment of some vaccines, which carries a high risk of immunopreventable diseases. 3 To maintain the success of the Brazilian National Immunization Program (PNI -Programa Nacional de Imunização), a wide extension of vaccination coverage is necessary, which requires adequate access for individuals to immunization services and the identification of factors that influence vaccination coverage. 4 However, the way to provide health and provide care based on the comprehensiveness of care to users is affected by obstacles resulting from the organizational model observed in PHC. 5 A study conducted in a PHC unit in a municipality in the state of Rio Grande do Sul, Brazil, revealed that care practices adopted by nurses, such as the establishment of shifts for vaccination room operation, resulted in restriction of access, making user' right to this service impossible. Efforts should be made to maintain a constant evaluation of the organizational model developed by PHC so that the bureaucratic aspects and established norms do not compromise the imperative of PHC to be welcoming and resolutive 5 .
Although universal access is a principle of SUS, the obstacles in organizational aspects indicate that care is centered on services' needs and not those of users, which limits the universalizing character of the system and causes situations of exclusion and inequality in access to health services. These obstacles compromise the maintenance of the success of PNI and, consequently, the control of immunopreventable diseases.
In this context, the question is: how does access to vaccination occur in the daily routine of PHC from users' perspective considering organizational aspects?
This study aimed to understand access to vaccination and its organizational aspects in the daily life of PHC from users' point of view.

METHOD
This is a holistic-qualitative multiple case study, 6 based on the theoretical framework of Comprehensive Sociology of Everyday Life. 7 The study setting was the West Minas Gerais Extended Health Region, which consists of 54 municipalities grouped into six health microregions. However, through the criteria of data saturation by literal replication 6 , four health microregions were included, since saturation in the fourth microregion surveyed was confirmed, leading to the closure of data collection.
In order to obtain representativeness of different realities and so that the results could have the capacity of generalization in qualitative research, in each microregion the municipalities were classified according to population size, ESF coverage, number of vaccination rooms and territorial 4/13 extension. The selected municipalities present divergent characteristics in relation to the selection criteria defined a priori, three of which are large, two medium-sized and two small. Two have 100% FHS population coverage and five have population FHS coverage smaller than 100%. The number of vaccination rooms ranged from two to 35 rooms, with variation in relation to territorial extension.
The number of cases considered necessary in multiple case studies should take into account a discretionary judgment, i.e. the number of complications will be conditional on the level of certainty that is intended to be obtained. 6 The logic of discretionary judgment, for the definition of the number of sufficient cases, is equivalent to the logic of caseless studies. These studies establish criteria to define a "significant effect" on experimental science. In clinical research, the researcher usually defines a significance level of "p < 0.01", but, depending on the circumstances, may choose to reach an even stricter level. Similarly, the designation of the number of replications in multiple case studies depends on the certainty that the researcher wishes to obtain about the results and the feeling about the strength and importance of rival explanations. 6 In this study, this level was affirmed with data collection in the fourth microregion, totaling seven municipalities and 25 PHC units. This level was confirmed by data saturation by literal replication 7 and by the finding that the collected data were sufficient to meet the method and the proposed objective.
Case studies present the generalization capacity in relation to theoretical propositions. Therefore, its goal is to expand and generalize theories (analytical generalization). 6 Thus, the findings of this study have the potential to extend to similar situations, conferring the capacity of external generalization in qualitative research.
Participants were 74 users who attended one of the health units visited at data collection time for vaccination or for other care. These were approached while waiting for the service. It was adopted as inclusion criterion to be 18 years of age or older, and as an exclusion criterion to be a person unable, temporarily or permanently, to legally answer for their acts. Twenty-two approaches were performed, and eight users refused to participate in the research.
As evidence data sources, we used the open and intensive individual interview, guided by a semi-structured script, that approached users in view of their access to vaccination in PHC; the technical visit to the vaccine rooms, and field notes for technical visit data records and for operational research development notes. A priori was pre-tested for the interview script.
Data were collected between June 2016 and April 2017.The interviews were conducted by a researcher trained to mediate continuous interaction between the collected and in-depth data and the theoretical subject of the study. They had an average duration of ten minutes, with a significant variation in duration time. Participants were randomly selected, presenting different forms of argumentation and elaboration of their statements through peculiar experiences in relation to access to vaccination.
The interviews were conducted according to the availability of users in a private space in the health unit itself; were recorded in digital file and later transcribed literally, preserving information reliabilit. To maintain participants' and microregions' confidentiality and anonymity, alphanumeric codes symbolized by letter "I" (interviewee) followed by the interview number sequentially and one of the numbers 1, 2, 3 or 4, respective to the four sanitary microregions, were used.
Data analysis was based on thematic content analysis, performed according pre-analysis, which aimed to make operational and systematize the initial ideas; material exploitation, which consisted of data codification and categorization; treatment of results; inference and interpretation. 8 Analysis followed the analytical technique of cross-synthesis of cases, in line with the methodological framework holistic-qualitative multiple case study. 6 The analysis of each case was performed individually for the four sanitary microregions.

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This research was approved by the Research Ethics Committee and is part of the Integrated Project "PreveNIr: Avaliação da qualidade do PNI na região Ampliada de Saúde Oeste de Minas Gerais", funded by Research Program for SUS. It was developed according to Resolution of the Brazilian National Health Council (Conselho Nacional de Saúde) 466 of December 12, 2012, following the guidelines and regulatory standards of research involving human beings.

RESULTS
Of the 74 participants in this study, 63 (85.1%) were female. The predominant age group was 26 to 33 years (32.4%). Most (85.1%) live in urban areas and are Catholic (78.4%). The technical visit to the vaccine rooms and the records in field notes (FN) allowed the apprehension of aspects related to location, organizational structure and resources, evidencing hinderers and facilitators of access by information, reception and physical structure.
Of the 25 PHC units visited, only one did not have a vaccination room. In this unit, vaccination is carried out only on Monday morning, and immunobiologicals are transported in thermal box. On the day of data collection, it was possible to verify that the vaccine box arrived at 8:00 a.m. and at 10 a.m., the doses of the yellow fever vaccine were over and many users waiting for vaccination were not contemplated. In one unit, the vaccination room had been deactivated for six months due to technical problems with the refrigerator and users were being referred and instructed to look for the health unit in the nearest neighborhood (FN).
Of the 23 operating rooms, it was identified that in 19  Some health units generally establish specific days for the vaccination of some immunobiologicals, which are presented in multi-dose vials, restricting and hindering, even more, access to immunization services.
It seems that they have the right day to open the vaccine. There was the day of the vaccine [...] I did not come on the right day because I did not know (I20-2).
The structure, cleaning, disinfection, organization of the vaccination room as well as preparation for the procedure were pointed out as determining items in decision-making to vaccinate: Look

DISCUSSION
PHC, coordinator of health care and preferential gateway to the SUS, has the function of providing longitudinal and comprehensive care that meets the needs of the population, promoting facilitated and inclusive access through the adoption of work routines for user-centered care. 5 Nevertheless, in order to meet users' demands, health services, contradictorily, define ways of functioning, establishing, for instance, days and times for vaccination, dressings and other procedures. 9 In the present study, it was observed the routine establishment of a single day of the week for the performance of the vaccine against yellow fever, triple viral and BCG, immunobiologicals that present in multidose vials. In such cases, care should be given to the validity of the vaccine after opening the vial, according to the manufacturer's guidelines and PNI standards. After the deadline, which, for these immunobiologicals, varies from 6 to 8 hours, vaccines should be discarded, which will lead to technical loss, i.e., loss of the remaining doses that were not applied because there is no demand. This type of loss is considered complex and hardly avoided. 10 It is necessary to consider the possibility that the measures used to reduce vaccine losses, such as the reduced number of days for the performance of certain vaccines, and the refusal to administer immunization, which would require the opening of multidose vials, are contributing to the decrease in vaccination coverage. 11 The implementation of strategies to reduce vaccine losses of technical origin should be adopted with caution or in specific situations of immunobiological defueling, since the opportunity to immunize cannot be missed.
It is noteable that during the data collection period of this study, favorable conditions of yellow fever transmission were presented in Brazil and the occurrence of measles outbreaks in several European countries. Thus, the Ministry of Health, through Information Notes 02/2017 12 and 10/2017, 13 warned, respectively, about the need to intensify surveillance and prevention actions for yellow fever, with an increase in vaccine supply and that all Federated Units maintain active epidemiological surveillance in the identification and follow-up of suspected cases of measles, maintaining high vaccination coverage and guidance to the population on the importance of updating the vaccine card.
Limited working hours configure a barrier and indicate that the call is centered on service's needs and not users'. To achieve the immunization policy, it is necessary a network of services increasingly close to users, meeting the demands of people's daily lives. In this study, the opening hours and the forms of organization of care in vaccine rooms emerged as factors that limit the use of immunization services, mainly due to the share of users inserted in the labor market, who, consequently, have less time to seek this care.
To focus on the daily life of the vaccination room, in the context studied, with its forms of work production in vaccination and expression of users, in front of this service, tells us that in the understanding of this phenomenon, the object is how the subject perceives it, interprets the world and expresses its experiences. 14 Health units that establish standards to meet vaccination, according to the needs of the services, approach what "can be modeled at will, but which, on the contrary, resists the rationalist injunction or at least relativizes it" 15 and induces to consider, relatively, the principle of access to the vaccine and the norms and guidelines of the PNI.
In a municipality participating in this study, it was possible to observe that, on one day of the week, all health units operated until 6:30 p.m. with the objective of assisting workers (FN).
The expansion of the opening hours of health services, especially at night, facilitates access for working users, 16 promoting immunization opportunities and increasing vaccination coverage among this public. On the other hand, if the hours of operation of the units do not meet users' needs, service satisfaction decreases by 46%, compromising the access and credibility of the population with PHC. 17 It was identified that aspects related to the physical structure, cleanliness and organization of vaccination rooms are factors that influence decision-making to vaccinate. A study that evaluated the structure and process of 93 vaccine rooms in PHC units in the city of Fortaleza, Ceará, Brazil, identified the inadequacy of the general cleaning of the vaccination room and refrigerators, the insufficient quantity of vaccines, syringes and needles, and the recording of temperatures that differ to the recommended for the proper conservation of vaccines. 18 Another study that evaluated the physical and structural conditions of 21 vaccination rooms in the health units of the city of Caxias, Maranhão, Brazil showed that, although all vaccination rooms are easily accessible to the public, 37.5% achieved a failure due to the inadequacy of essential items for the promotion of safety during the procedure, deficits of indispensable materials and lack of all immunobiologicals in 88% of the vaccination rooms surveyed. 19 Lack of vaccines entails missed immunization opportunities, which may reflect the discredit of services by the population, impairing the scope and maintenance of vaccination coverage. 20 This finding of lack of immunobiological was also found in a study conducted in Guatemala, where participants indicated that this is one of the reasons for the delayed vaccination situation 20 . Also, in a study that evaluated the quality of organization and functioning of vaccine rooms of a municipality in northern Minas Gerais, Brazil, there was an unavailability of some routine vaccines in 17 of the 18 rooms evaluated. 21 These findings corroborate the results of the present study, showing that the impairment of immunization practices, because of the scarcity of immunobiologicals, is not only a problem in the region of Minas Gerais surveyed.
Lack of access to information can be determinant for the establishment of of a person's health habits, increasing the likelihood of non-smoking or delayed immunization of individuals. 22

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Contradictorily, the indication of the vaccine and the information about its benefits are strategies for greater immunization ideation. A study that aimed to estimate vaccination coverage against Hepatitis B in adolescents and identify the reasons for the non-vaccine adhering found that one of the main reasons cited by adolescents with a delayed vaccination schedule was lack of information and guidance on the need for a three-dose vaccine regimen. It is evident that lack of guidance by health professionals was strongly associated with non-adhering to the Hepatitis B vaccine. 23 On the other hand, a study that aimed to discuss the actions developed by nurses for the control and eradication of immunopreventable diseases identified that the main actions developed involve updating the vaccine card, guiding users and referring to the vaccination room. The contents covered during the guidelines cover the importance of keeping the vaccination card up to date, specifying the types of vaccines and their importance. However, it is noteworthy that these guidelines are directed, fundamentally, to the mothers of children and pregnant women. 24 There is, in the simple sense of access to information, on the relevance of the vaccine and the appropriate guidelines for the process of vaccinating, "a competition between archaic elements and technological development". 15:148 It is evidenced by the perspective of expanded understanding of the need for union between specialized knowledge and world knowledge: "ally against, make them be in synergy", 14:148 understanding and contaminating the way of being and thinking of users in the face of the need for vaccination.
Specific guidelines on the dates for the next vaccination and the number of doses required to ensure the immunogenicity of vaccines are information that directly influences the use of immunization services and is often performed inconsistently. 20 A study conducted in a low-income community in New York City revealed that the majority of vaccine doses against influenza in the season studied were administered in scheduled visits (80% of the first doses, 57% of the second doses). This vaccination schedule was pointed out by users as a practice that promoted access to vaccines. 25 The present study demonstrated that direct contact and insertion of users in other actions and services of the health unit, such as prenatal consultation, favors access to vaccination. Such occasions are a moment with great potential to favor and expand the opportunities for orientation for vaccination, providing the referral of users who are not vaccinated or with incomplete schedules to the vaccination room. Therefore, it is essential that all members of the health team are involved and committed to vaccination. 26 A survey conducted in Pakistan, which aimed to identify factors associated with arrears vaccination among children, found that children of mothers who did not have access to prenatal services were more likely to have a delayed vaccination status. It is evident that the immunization of children is not an isolated phenomenon, as it is associated with the previous and timely interaction of parents with the health system. 24 Users recommended actions that could be adopted as strategies to promote the use of immunization services, thus suggesting a schedule for better access to the vaccination room. This schedule indicates the need to reorganize the days and times available for vaccination, increasing the accessibility of the population to the service; the computerization of the vaccine card; the implementation of specific dissemination strategies to increase awareness and, consequently, the search for immunization; the structural adequacy of the vaccination room and the expansion of human resources in health units in order to reduce the waiting time for vaccination.
Disseminating the importance of vaccination, extending the hours of care in health units 27 and disseminating events related to vaccination in public environments, schools and community centers 20 were also suggested strategies to promote the adoption of immunization actions by research participants conducted in Joinvile, Santa Catarina, Brazil and Guatemala.

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The media is an important means of disseminating health information, having been described as the main tool for disseminating actions in vaccination. However, because it is passive, does not, in fact, intervene in people's health education. The importance of an active action of Community Health Workers (CHW) with the population 27 stands out. The research conducted in Joinvile, when analyzing the reasons for non-adoption of children to the vaccination campaign against influenza, identified that disclosure through CHW was ineffective. 27 Nurses may, in this case, be effective in their managerial competence.
Finally, considering the organizational aspects for access to vaccination implies, based on the Comprehensive Sociology of Daily Life, "uniting the opposites: operating knowledge and, at the same time, perceiving vital drive, knowing and being able to understand existence", 15:58 to meet users' needs and have the right to vaccinate.
This study presents as a limitation the intentional sampling, when selecting only one subgroup of the user population present in PHC units on the day of data collection. However, based on the information collected, intentional sampling can be considered representative in populations and similar conditions in multiple case studies with data saturation by literal replication.

CONCLUSION
In the present study, there were organizational obstacles that compromise the provision of an adequate vaccination service, as established by the PNI. These obstacles are configured in the establishment of specific days for the performance of certain vaccines; in the restricted opening hours of vaccination rooms; lack of immunobiological scans and lack of guidance and clarification by health professionals. It was evidenced that direct contact and insertion of users in other actions and services of the health unit favor access to vaccination.
The routine establishment of only one day of the week for the performance of vaccines presented in multi-dose vials, as a measure to reduce vaccine losses of technical origin, was not a strategy described in the literature consulted. Further research in this area is needed, as studies are incipient on optimized immunization measures and practices that present potential strategies to reduce technical losses, without compromising individuals' access to timely immunization.
Aiming at the wide dissemination of information related to immunization, we highlight the role of nurses, technical responsible for immunization activities in PHC, in continuing education actions for the nursing team and CHW, as well as guidance in relation to the activities to be developed by these professionals in the territory.
A schedule for the best access was recommended by users. They indicated the reorganization of days and times for vaccination, in line with population's needs; the computerization of the vaccine card; the implementation of specific dissemination strategies to expand the search for immunization; structural adequacy of the vaccination room; and expansion of human resources in health units.
Despite the entire political and institutional framework for SUS implementation and the realization of users' access to health services and actions, it was possible to confirm, in this study, that there are many barriers that need to be faced by public institutions to offer assistance to everyone in the vaccination room, in respect of the principles of universality, equity, and comprehensiveness. Therefore, the importance of health services identifying their weaknesses and seeking strategies and alternatives that enable user-centered care is emphasized, in order to promote the maintenance of adequate rates of vaccination coverage and, consequently, the success of PNI.