Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based randomized-controlled trial in Karachi, Pakistan

"If the food is finished after my brother eats then we (girls) sleep hungry." Food insecurity and dietary diversity among slum-dwelling adolescent girls and boys in Pakistan: A mixed methods study

To explore gender differences in food insecurity (FI) and minimum dietary diversity (MDD) among adolescent girls and boys in a slum community in Karachi, we employed an explanatory sequential mixed methods study that included a survey of 391 girls and boys of 10-19 years of age and followed by semi-structured interviews of eight purposely selected food insecure adolescents. Survey data was analyzed by Cox proportional algorithm and adjusted prevalence ratios (APR) with 95% confidence intervals (CI) were estimated for associated factors of FI and thematic analysis was undertaken for qualitative work. Meta inferences for mixed methods study were drawn by joint display analysis of survey results juxtaposed to qualitative findings. Overall, FI among adolescents was prevalent (46.5%) which was not different between boys (52.7%) and girls (47.3%) (APR 0.8, (95% CI 0.6, 1.2); p-value-0.4). MDD (5/10 food groups consumed) was achieved by only 23.0% and it was also not different between boys (25.1%) and girls (20.9%) (p-value-0.3). The survey found no significant difference in FI and MDD between boys and girls however, qualitative findings provided insight into the cultural practices at mealtimes that prefer boys. Qualitative results contrasted the survey results and revealed the increased vulnerability of girls towards FI and low MDD compared to boys due to gender norms.

Interventions for improving coverage of childhood immunisation in low- and middle-income countries

BACKGROUND

Immunisation plays a major role in reducing childhood morbidity and mortality. Getting children immunised against potentially fatal and debilitating vaccine-preventable diseases remains a challenge despite the availability of efficacious vaccines, particularly in low- and middle-income countries. With the introduction of new vaccines, this becomes increasingly difficult. There is therefore a current need to synthesise the available evidence on the strategies used to bridge this gap. This is a second update of the Cochrane Review first published in 2011 and updated in 2016, and it focuses on interventions for improving childhood immunisation coverage in low- and middle-income countries.

OBJECTIVES

To evaluate the effectiveness of intervention strategies to boost demand and supply of childhood vaccines, and sustain high childhood immunisation coverage in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, CINAHL, and Global Index Medicus (11 July 2022). We searched Embase, LILACS, and Sociological Abstracts (2 September 2014). We searched WHO ICTRP and ClinicalTrials.gov (11 July 2022). In addition, we screened reference lists of relevant systematic reviews for potentially eligible studies, and carried out a citation search for 14 of the included studies (19 February 2020).

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs), non-randomised RCTs (nRCTs), controlled before-after studies, and interrupted time series conducted in low- and middle-income countries involving children that were under five years of age, caregivers, and healthcare providers.

DATA COLLECTION AND ANALYSIS

We independently screened the search output, reviewed full texts of potentially eligible articles, assessed the risk of bias, and extracted data in duplicate, resolving discrepancies by consensus. We conducted random-effects meta-analyses and used GRADE to assess the certainty of the evidence.

MAIN RESULTS

Forty-one studies involving 100,747 participants are included in the review. Twenty studies were cluster-randomised and 15 studies were individually randomised controlled trials. Six studies were quasi-randomised. The studies were conducted in four upper-middle-income countries (China, Georgia, Mexico, Guatemala), 11 lower-middle-income countries (Côte d'Ivoire, Ghana, Honduras, India, Indonesia, Kenya, Nigeria, Nepal, Nicaragua, Pakistan, Zimbabwe), and three lower-income countries (Afghanistan, Mali, Rwanda). The interventions evaluated in the studies were health education (seven studies), patient reminders (13 studies), digital register (two studies), household incentives (three studies), regular immunisation outreach sessions (two studies), home visits (one study), supportive supervision (two studies), integration of immunisation services with intermittent preventive treatment of malaria (one study), payment for performance (two studies), engagement of community leaders (one study), training on interpersonal communication skills (one study), and logistic support to health facilities (one study). We judged nine of the included studies to have low risk of bias; the risk of bias in eight studies was unclear and 24 studies had high risk of bias. We found low-certainty evidence that health education (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.15 to 1.62; 6 studies, 4375 participants) and home-based records (RR 1.36, 95% CI 1.06 to 1.75; 3 studies, 4019 participants) may improve coverage with DTP3/Penta 3 vaccine. Phone calls/short messages may have little or no effect on DTP3/Penta 3 vaccine uptake (RR 1.12, 95% CI 1.00 to 1.25; 6 studies, 3869 participants; low-certainty evidence); wearable reminders probably have little or no effect on DTP3/Penta 3 uptake (RR 1.02, 95% CI 0.97 to 1.07; 2 studies, 1567 participants; moderate-certainty evidence). Use of community leaders in combination with provider intervention probably increases the uptake of DTP3/Penta 3 vaccine (RR 1.37, 95% CI 1.11 to 1.69; 1 study, 2020 participants; moderate-certainty evidence). We are uncertain about the effect of immunisation outreach on DTP3/Penta 3 vaccine uptake in children under two years of age (RR 1.32, 95% CI 1.11 to 1.56; 1 study, 541 participants; very low-certainty evidence). We are also uncertain about the following interventions improving full vaccination of children under two years of age: training of health providers on interpersonal communication skills (RR 5.65, 95% CI 3.62 to 8.83; 1 study, 420 participants; very low-certainty evidence), and home visits (RR 1.29, 95% CI 1.15 to 1.45; 1 study, 419 participants; very low-certainty evidence). The same applies to the effect of training of health providers on interpersonal communication skills on the uptake of DTP3/Penta 3 by one year of age (very low-certainty evidence). The integration of immunisation with other services may, however, improve full vaccination (RR 1.29, 95% CI 1.16 to 1.44; 1 study, 1700 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Health education, home-based records, a combination of involvement of community leaders with health provider intervention, and integration of immunisation services may improve vaccine uptake. The certainty of the evidence for the included interventions ranged from moderate to very low. Low certainty of the evidence implies that the true effect of the interventions might be markedly different from the estimated effect. Further, more rigorous RCTs are, therefore, required to generate high-certainty evidence to inform policy and practice.

Community-based participatory research to engage disadvantaged communities: Levels of engagement reached and how to increase it. A systematic review

Community-based participatory research (CBPR) is one of the most used community engagement frameworks to promote health changes in vulnerable populations. The more a community is engaged, the more a program can impact the social determinants of health. The present study aims to measure the level of engagement reached in randomized controlled trials (RCTs) using CBPR in disadvantaged populations, and to find out the CBPR components that better correlate with a higher level of engagement. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Embase, Web of Science, MEDLINE, Cochrane and Scopus databases were queried. Engagement level was assessed using the revised version of IAP2 spectrum, ranging from "inform" to "shared leadership" . Fifty-one RCTs were included, belonging to 36 engagement programs. Fourteen CBPR reached the highest level of engagement. According to the multivariate logistic regression, a pre-existing community intervention was associated with a higher engagement level (OR = 10.08; p<0.05). The variable "institutional funding" was perfectly correlated with a higher level of engagement. No correlation was found with income status or type of preventive programs. A history of collaboration seems to influence the effectiveness in involving communities burdened with social inequities, so starting new partnerships remains a public health priority to invest on. A strong potentiality of CBPR was described in engaging disadvantaged communities, addressing social determinants of health. The key findings described above should be taken into account when planning a community engagement intervention, to build up an effective collaborative field between researchers and population.

Changes in immunization coverage and contributing factors among children aged 12-23 months from 2000 to 2019, Ethiopia: Multivariate decomposition analysis

BACKGROUND

Immunization has been promoted as a global strategy aimed at improving child survival. The World Health Organization strives to make immunization services available to everyone, everywhere to save over 50 million lives by 2030. Monitoring the change and identifying the factors contributing to the change in immunization coverage over time and across the nations is imperative for continuing global success in increasing immunization coverage. In this study, we examined the changes and factors that contributed to the change in full immunization coverage over time in Ethiopia (2000 to 2019).

METHODS

We analyzed data on children aged 12-23 months, extracted from the 2000 and 2019 Ethiopian Demographic and Health Survey (EDHS) datasets. A total of 3,072 weighted samples (2,076 in 2000 and 966 in 2019) were included in the analysis. A multivariate decomposition analysis technique was used to determine change and identify factors that contributed to the change over time. Statistical significance was defined at a 95% confidence interval with a p-value of less than 0.05.

RESULTS

There was a 29.56% (95% CI: 24.84, 34.28) change in full immunization coverage between the two surveys. It increased from 14.62% (95% CI: 12.43, 17.11) in 2000 to 44.18% (95% CI: 37.19, 51.41) in 2019. The decomposition analysis showed that about 75% of explained change was attributed to the differences in the composition of explanatory variables (the endowment effect). Particularly, women aged 35-49 years (-2.11%), those who attended four or more antenatal care visits (17.06%), individual who had postnatal care visits (16.90%), households with two or more under-five children (2.50%), and those with a history of child mortality (17.80%) were significantly attributed to the change. The rest, 25% of the explained change was attributed to the difference in the effects of explanatory variables (coefficient). The change in the coefficient for women who had experienced child death (-20.40%) was statistically significant to the change in full immunization coverage over time.

CONCLUSION

The finding of this study revealed that there was a statistically significant change in full immunization coverage over time. The majority of the change was attributed to the differences in the composition of explanatory variables such as antenatal care and postnatal care visits, age of the mother, and number of living children in the household. Therefore, strengthening maternal health services utilization may enhance immunization coverage in Ethiopia. Furthermore, the difference in coefficient of mothers with a history of child death had a substantial counteracting effect on the change, emphasizing the importance of raising awareness and delivering vaccine education to them and the larger community.

Urban-rural disparities in immunization coverage among children aged 12-23 months in Ethiopia: multivariate decomposition analysis

BACKGROUND

Immunization is one of the most cost-effective public health interventions for improving children's health and survival. In Ethiopia, low immunization coverage and disparity across residences are major public health problems. However, the factors that contributed to the urban-rural disparity have not been thoroughly investigated. Therefore, the objective of this study was to examine the change and contributing factors in full immunization coverage across geographic locations (urban-rural) in Ethiopia.

METHODS

We analyzed data on children aged 12 to 23 months obtained from the 2019 mini-Ethiopian demographic and health survey. A total of 996 weighted samples (299 in urban and 697 in rural areas) were included in the analysis. A multivariate decomposition analysis technique was used to determine the disparity and identify factors that contribute to the disparity across geographical locations. Statistical significance was defined at a 95% confidence interval with a p-value of less than 0.05.

RESULTS

The percentage of children aged 12-23 months who received full immunization increased from 36.84% (95% CI:31.59, 42.41) in rural areas to 64.59% (95% CI:47.10, 78.89) in urban areas. The decomposition analysis showed that the observed urban-rural disparity was attributed to a change in the effect of population characteristics (coefficient) across residences. Specifically, receiving 1-3 (β = 0.0895, 95% CI: 0.0241, 0.1550) and 4 or more (β = 0.1212, 95% CI: 0.0224, 0.2199) antenatal care visits, delivering at a health facility (β = 0.1350, 95% CI: 0.0227, 0.2472), and the source of information about immunization status from vaccination cards (β = 0.2666, 95% CI:0.1763, 0.3569) significantly contributed to the widening urban-rural disparity. On the other hand, being of high wealth status (β=-0.141, 95% CI: -0.1945, -0.0876), receiving postnatal care (β=-0.0697, 95% CI: -0.1344, -0.0051), and having four or more living children (β=-0.1774, 95% CI: -0.2971, -0.0577) significantly contributed to narrowing the urban-rural disparity.

CONCLUSIONS

There was a significant urban-rural disparity in immunization coverage in Ethiopia, with urban children more likely to complete immunization. The change in the composition of population characteristics was not significant for the observed disparity. The observed disparity in full immunization coverage was mainly driven by the coefficients related to maternal healthcare utilization, household wealth status, the number of living children, and the source of immunization information. Therefore, strengthening maternal health services utilization, encouraging mothers to maintain their children's immunization records, and addressing economic inequality, particularly in rural areas, may narrow the urban-rural disparity and enhance immunization coverage nationwide.

"We are their eyes and ears here on the ground, yet they do not appreciate us"-Factors influencing the performance of Kenyan community health volunteers working in urban informal settlements

This study explored factors that influence CHV performance in urban informal settlements (UIS) within Nairobi Kenya and ways in which CHVs can be supported to enhance their wellbeing and strengthen community strategies. The study was undertaken in two UIS within Nairobi County. Thirteen focus group discussions and three key informant interviews were conducted with a range of respondents. Various topics covering the design of the Community Health Strategy (CHS) and broader contextual factors that affect CHVs' performance, were discussed and data analysed using a framework analysis approach. The key programme design factors identified as influencing the performance of CHVs working in UIS included: CHV recruitment; training; availability of supplies and resources; and remuneration of CHVs. Health system factors that influenced CHVs performance included: nature of relationship between healthcare workers at local referral facilities and community members; availability of services and perceived corruption at referral facilities; and CHV referral outside of the local health facility. Whereas the broader contextual factors that affected CHV performance included: demand for material or financial support; perceived corruption in community programmes; and neighbourhood insecurity. These findings suggest that CHVs working in UIS in Kenya face a myriad of challenges that impact their wellbeing and performance. Therefore, to enhance CHVs' well-being and improve their performance, the following should be considered: adequate and timely remuneration for CHVs, appropriate holistic training, adequate supportive supervision, and ensuring a satisfactory supply of resources and supplies. Additionally, at the facility level, healthcare workers should be trained on appropriate and respectful relations with both the community and the CHVs, clarity of roles and scope of work, ensure availability of services, and safeguard against corrupt practices in public health facilities. Lastly, there's a need for improved and adequate security measures at the community level, to ensure safety of CHVs as they undertake their roles.

Theory-based immunisation health education intervention in improving child immunisation uptake among antenatal mothers attending federal medical centre in Nigeria: A study protocol for a randomized controlled trial

BACKGROUND

Childhood immunisation coverage is very low in Nigeria (31%) with Zamfara State being amongst the states with the poorest coverage (<10%). Lack of maternal knowledge, attitude, outcome expectations, self-efficacy, cultural beliefs and assumptions of religious regulations of antenatal mothers towards childhood immunisation are the contributory factors to poor childhood immunisation uptake. This study aims is to develop, implement and evaluate the effects of an immunisation health educational intervention with application of Social Cognitive Theory on pregnant women to improve knowledge, attitude, outcome expectations, self-efficacy, cultural beliefs and assumptions on religious regulations regarding childhood immunization uptake in Federal Medical Centre Gusau, Zamfara State, Nigeria.

METHODOLOGY

The study will be a single-blind parallel-group randomised controlled trial, where baseline data will be collected from 392 estimated antenatal mothers, after that they will be evenly randomised using randomly generated permuted block sizes (each containing two intervention and two control assignments). The study participants will be antenatal mothers of ages 18 years and above who are in third trimesters and attending Federal Medical Centre Gusau, Zamfara State, Nigeria; during the study period and fulfilled all the inclusion and exclusion criteria. The intervention group will undergo five-health education sessions on immunisation, which will be strictly guided by Social Cognitive Theory-based intervention module: while the control group will receive usual care (standard care). Follow-up data will be collected using the same questionnaire at 6-weeks post-delivery, 10-weeks post-delivery and 14-weeks post-delivery. The generalized linear mixed model will be carried-out to determine the overall effect of the intervention after controlling for 14 potential confounding variables. An intention to treat analysis will also be carried-out. Childhood immunisation uptake is the primary outcome while the secondary outcomes are: improved knowledge scores, attitude scores, outcomes expectation, self-efficacy scores, cultural beliefs scores and assumptions on religious regulations scores.

DISCUSSION

The study will be a randomised controlled trial, that focuses on the effects of an immunisation health educational intervention with application of Social Cognitive Theory on pregnant women to improve knowledge, attitude, outcome expectations, self-efficacy, cultural beliefs and assumptions on religious regulations regarding childhood immunisation uptake in Federal Medical Centre Gusau, Zamfara State, Nigeria.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR202006722055635. Protocol registered on 09 June 2020.

Perceptions of childhood vaccination practices among beneficiaries and healthcare service providers in slums under the national immunization program of India: a qualitative study

Purpose

A qualitative study can help in understanding the unpolluted perspectives of key stakeholders involved in the vaccination practices and can explore vital factors that could influence vaccination-related behaviors and their utilization. This study aims to document the perceptions of caretakers, community members and healthcare service providers related to childhood vaccination practices in slums under the national immunization program (NIP) of India.

Design/methodology/approach

This was a qualitative community-based cross-sectional study. Focus group discussions with caretakers, community members and healthcare service providers were used to build a holistic, detailed description and analysis of the factors associated with childhood vaccination practices within its real-world context.

Findings

Lack of awareness, fear of adverse events following immunization, inappropriate timing of vaccination sessions, loss of daily earnings, migration, lack of good behavior of health staffs, shortage of logistics and vaccines, limited resources and infrastructures and high expectations of beneficiaries were some of the vital barriers impacting vaccination practices in slums.

Research limitations/implications

Though this study provides significant good information on the indicators that can be considered to improve the vaccination practices in any slum settings, it has is also a limitations too due to its setting. Therefore, one needs to be cautious while generalizing these results to other settings like rural. In addition, Though we believe that these strategies could be useful in any setting, it is also important to tailor these observations them as per the need of the society and the population. Also, this is a self-reported qualitative study and therefore the perspectives reported in this study need to be taken with caution. Further, low vaccination, poor awareness, compromised healthcare services, high expectations could be considered as a stigma/fear among the responders and therefore there is always a chance of underreporting. Thus, it would be important in future to conduct a study involving a broader group of people in society and to establish factors associated with the vaccination coverage. that can help in improvement of vaccination.

Originality/value

Initiatives such as regular interactions at different levels, effective communication including reminders, behavior interventions, the continued supply of vaccines and logistics, additional resources for the vaccination program, incentives and recognition, extended sessions and people-friendly healthcare delivery system could be helpful to strengthen the routine vaccination practices in slums.

Association Between Nutrition Social Behavior Change Communication and Improved Caregiver Health and Nutrition Knowledge and Practices in Rural Tanzania

Background

Efforts to improve infant and young child feeding practices include the use of nutrition behavior change communication among caregivers of children under 5 years. We assessed the association between monthly participation in community-level nutrition group meetings on caregiver health and nutrition knowledge and practices (KPs).

Methods

Data from a community-based cross-sectional survey conducted in the Eastern and Southern Highland Zones of Tanzania were used. Indices were developed for caregivers' knowledge of nutrition, health and childcare, household (HDD) and young child dietary diversity (CDD), and vitamin A (VA) intakes. The comparison of means and proportions was assessed using Student's t-test and the Chi-square test, respectively, between the caregivers participating in nutrition group meetings and non-participants. The impact of the number of nutrition meeting attendance on caregiver KPs scores was examined using multiple regression.

Results

Of 547 caregivers surveyed, 49.7% attended nutrition group meetings and received information on nutrition social behavior change communication (SBCC). Overall, 28% of participating women had a moderate level of nutrition knowledge, 62% had a high level of VA knowledge, and 57% had a high level of health and childcare knowledge. Participation in nutrition group meetings was significantly associated with the health and childcare knowledge score (HKS), HDD and CDD scores, and household and young child VA intake; the magnitude of the associations was greater for caregivers who attended at least four meetings.

Conclusion

The findings emphasize the need for programs that seek to address the issues present in the use of nutrition SBCC at the community level to improve maternal or caregiver KPs and subsequently the nutrition status of infants and young children.

Spatial distribution and associated factors of measles vaccination among children aged 12-23 months in Ethiopia. A spatial and multilevel analysis

INTRODUCTION

In Ethiopia, measles continues to be the cause of a significant number of vaccine-preventable infant morbidity and mortality due to the low vaccination rate. However, understanding the geographical distribution of the measles-containing vaccine first dose (MCV1) and identifying associated factors is crucial to setting up appropriate interventions. This study aimed to explore the spatial distribution and associated factors of MCV1 coverage among children aged 12-23 months in Ethiopia using national representative data.

METHODS

A cross-sectional study design using a two-stage stratified sampling technique was used. The analysis was performed using STATA 14.2, ArcGIS 10.8, and SaTScan version 9.6 software. To find significant related factors with measles vaccination, researchers used multilevel logistic regression.

RESULTS

The prevalence of MCV1 in Ethiopia was 58.5%. A spatial variation of MCV1 coverage was observed across the study area. The most likely significant primary clusters with low MCV1 coverage were observed in Liben, Afder, Shebelle, Korahe, and Nogob zones of the Somali region; Bale and Guji zones of the Oromia region, and Gedeo and Sidama zones of the SNNPR. Rural areas, maternal primary education, secondary and above school education, Orthodox religion, Muslim religion, health facility delivery, and Afar region were significantly associated with MCV1 vaccination.

CONCLUSION

The overall MCV1 coverage in Ethiopia was low. Aside from the inadequate coverage, there was a geographical variation across the country. Low MCV1 coverage areas should be prioritized to improve vaccination efforts to control measles across the country.

A 10+10+30 radio campaign is associated with increased infant vaccination and decreased morbidity in Jimma Zone, Ethiopia: A prospective, quasi-experimental trial

Mass media interventions have the potential to reach large audiences and influence health behaviours and outcomes. To date, no study has evaluated the effect of a radio-only campaign on infant vaccination coverage, timeliness, and related morbidity in a low-income country. We implemented the "10+10+30" radio campaign involving broadcasting a weekly 10-minute radio drama series on vaccination, followed by a 10-minute discussion by community health workers, and then a 30-minute listener phone-in segment in Jimma Zone, Ethiopia for three months. To assess the impact of 10+10+30, which was aired on a community radio station, we recruited mothers of infants up to 5 weeks old in intervention district clusters that were inside the radio station's reception range (n = 328 dyads) and control district clusters that were outside of the range (n = 332 dyads). Intention-to-treat and per-protocol analyses, adjusted for pre-intervention differences between the districts, were conducted to examine the co-primary outcome of Penta-3 vaccination coverage and timeliness as well as those of other vaccines and outcomes related to infant morbidity. Both intention-to-treat and per-protocol analyses revealed higher vaccine coverage (p<0.001) and more timely vaccine administration (p<0.001) in the intervention district relative to the control district, with infants in the intervention district being 39% more likely to receive a Penta 3 vaccination (adjusted RR: 1.39, p<0.001). In addition, adjusted regression analyses of maternal retrospective reports over a two-week period revealed 80% less infant diarrhoea (RR: 0.20, p<0.001), 40% less fever (RR: 0.60, p<0.001) and 58% less cough (RR: 0.42, p<0.001) in the intervention district relative to the control district. This study provides compelling initial evidence that a radio drama integrated with discussion and phone-in components may improve infant vaccination coverage and timeliness, and may reduce infant morbidity. Randomized controlled trials are needed to confirm and extend these findings with other samples.

Pakistan Ranks Third Globally With the Most Unvaccinated Children: Is the Impact of Parental Perception and Attitude on Immunization an Essential Contributing Factor to an Unsuccessful Vaccination Coverage?

Introduction

Having the third-highest burden of child mortality and ranking third globally for the most under-vaccinated children, Pakistan contains 15% of its population under the age of five, which accounts for 50% of the mortality rate in this country. Every year, almost three million children miss out on an entire course of the most readily available vaccines, leaving them vulnerable to life-threatening diseases. The Expanded Program of Immunization (EPI) was launched in 1978 to protect children from vaccine-preventable childhood diseases. It is the main program through which routine immunization is provided to the public. However, since its inception within Pakistan, it has encountered many problems, including a lack of parental awareness and education. Low literacy rate, socio-economic disparities, cultural and religious beliefs have made parents doubtful about vaccinations. This term is known as vaccine hesitancy. Belief in conspiracy theories has also led to reduced vaccination coverage in Pakistan.

Methods 

A cross-sectional study was conducted on 300 parents with children under five, chosen from Karachi, Pakistan, through a convenience sampling technique. The data was collected via 300 self-administered or researcher administered questionnaires. Associations were evaluated using the chi-square test with the level of significance taken as p < 0.05 and Cramer's V to determine the strength of these associations. Data analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.0. 

Results 

Strong associations were found between parental knowledge of immunization, vaccines, and willingness to get their children immunized. Associations were greater and significant in parents with a higher level of education compared to lower. However, lack of knowledge about certain essential vaccines like Pentavalent, Pneumococcal, and IPV was an important aspect to consider. Also, it was noted that their inability to access these free vaccines was due to their own firm beliefs. It was also about the lack of awareness and facilities for a better and beneficial program. 22.3% of parents said that administering multiple vaccines at a time would be harmful to their child, and 21.7% believed it would cause the disease it's supposed to prevent. However, the majority of the parents said they would strongly recommend others to get vaccinated. In this study, religions included and investigated mostly encouraged vaccination to their relatives (p value= 0.079). Occupation and Monthly income had little to no effect on the immunization regime of young children. 

Conclusion

An impact of higher levels of education on the perceptions and attitudes of parents regarding the immunization of children was noted. Consequently, as religion, gender, occupation, and monthly income do not affect parents' perceptions regarding immunizations, the problem lies within their knowledge and understanding of basic medical science and easily communicable diseases. Oblivious to the consequences of contracting a lethal disease, it has developed a laid-back attitude amongst parents. Hence, awareness and education of parents regarding vaccine-preventable diseases by the healthcare system and the governing bodies can lead to a higher successful immunization rate.

Why parents bring their children with minor health problems to their family practitioners: An unmatched case-control study

Background:

Parents' of young children who frequently attend primary health care (PHC) services for mild health problems (MHPs) can present a complex and difficult challenge for staff. This phenomenon can expose the child to inappropriate overprescribing, unnecessary medical interventions and may impair the quality of life of parents and children.

Aim:

To define driving factors for frequent attenders (FAs) preschool children in PHC services in Kuwait.

Design and Setting:

An unmatched case-control study was conducted in the PHC setting in Kuwait.

Method:

A sample comprised of 300 parents from 10 PHC centres was selected. The top third children with higher frequency (FAs) visits to their family practitioners (FPs) were compared with the lower third with lower frequency (NFAs) visits to their FPs during the same duration. The Brief Illness Perception Questionnaire (Brief IPQ) was used to assess parents' response to their children's illness. The sociodemographic data for both groups were collected. Culture and background heath status for child and family were collected (order of the child in the family, if the family is living with the extended family and additional help received regarding childcare). The previous medical history of parent, child, and siblings was also included.

Results:

The mean number of consultations in FAs versus NFAs within the previous year was 15.5 ± 7.6 and 4.3 ± 2.1, respectively. There was no significant difference in means between the two groups of parents in responses to the questions of the adapted Brief IPQ. FAs were more likely to be the first-order child (odds ratio (OR) 2.4; 95% confidence interval (CI) =1.2–4.6), have chronic disease (OR 4.7; 95% CI = 2.1–10.6), and live with the extended family (OR 1.8; 95% CI = 1.1–3.3). They experienced an acute, potentially life-threatening episode previously (OR 2.6; 95% CI = 1.1–6.4), with the same applying to a sibling (OR 72.6; 1.2–6.2) or parent (OR 2.6; CI = 1.1–6.4).

Conclusion:

Identification of the hidden reasons that affect parents' decisions to consult their FPs frequently for their children's MHPs were important predictors for defining preschool FAs children in the PHC centres and can help the staff provide effective management plans to help them.

The role of access to electricity, female education, and public health expenditure on female health outcomes: evidence from SAARC-ASEAN countries

BACKGROUND

The importance of the status of female health should have research priority due to the unique medical needs of women. Hence this paper attempts to explore the nexus of access to electricity, female education, and public health expenditure with female health outcomes in the SAARC-ASEAN countries.

METHODS

Using the data of 2002-2018, and applying the cross-sectional dependence test, Modified Wald test, Wooldridge test, the Panel corrected standard error (PCSE) model, the Feasible generalized least square (FGLS) model, and the pair-wise Granger causality test, the robust outcomes on female health are found.

RESULTS

Access to electricity, female education rate, public health expenditure, economic growth, and immunization rate, all have a positive effect on female life expectancy at birth, and a negative effect on the female adult mortality rate. The urbanization rate has a significantly positive impact on female life expectancy at birth but an insignificant impact on female adult mortality rate. The one-way causal relationship between the variables are also revealed.

CONCLUSIONS

All the results are rational and have important milestone for the health sector. The health status of females should be improved and protected by formulating effective policies on access to electricity, female education, public health expenditure, immunization, economic growth, and urbanization.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Impact of universal home visits on child health in Bauchi State, Nigeria: a stepped wedge cluster randomised controlled trial

BACKGROUND

Nigeria is the second biggest contributor to global child mortality. Infectious diseases continue to be major killers. In Bauchi State, Nigeria, a stepped wedge cluster randomised controlled trial tested the health impacts of universal home visits to pregnant women and their spouses. We present here the findings related to early child health.

METHODS

The home visits took place in eight wards in Toro Local Government Authority, randomly allocated into four waves with a delay of 1 year between waves. Female and male home visitors visited all pregnant women and their spouses every 2 months during pregnancy, with a follow up visit 12-18 months after the birth. They presented and discussed evidence about household prevention and management of diarrhoea and immunisation. We compared outcomes among children 12-18 months old born to mothers visited during the first year of intervention in each wave (intervention group) with those among children 12-18 months old pre-intervention in subsequent waves (control group). Primary outcomes included prevalence and management of childhood diarrhoea and immunisation status, with intermediate outcomes of household knowledge and actions. Generalised Estimating Equations (GEE), with an exchangeable correlation matrix and ward as cluster, tested the significance of differences in outcomes.

RESULTS

The analysis included 1796 intervention and 5109 control children. In GEE models including other characteristics of the children, intervention children were less likely to have suffered diarrhoea in the last 15 days (Odds Ratio (OR) 0.40, 95% confidence interval (CI) 0.30-0.53) and more likely to have received increased fluids and continued feeding in their last episode of diarrhoea (OR 6.06, 95% CI 2.58-14.20). Mothers of intervention children were more likely to identify lack of hygiene as a cause of diarrhoea (OR 2.24, 95% CI 1.27-3.95) and their households had better observed hygiene (OR 3.29, 95% CI 1.45-7.45). Intervention children were only slightly more likely to be fully immunised (OR 1.67, 95% CI 0.78-3.57).

CONCLUSIONS

Evidence-based home visits to both parents stimulated household actions that improved prevention and management of childhood diarrhoea. Such visits could help to improve child health even in settings with poor access to quality health services.

TRIAL REGISTRATION

ISRCTN82954580 . Date: 11/08/2017. Retrospectively registered.

Unveiling and addressing implementation barriers to routine immunization in the peri-urban slums of Karachi, Pakistan: a mixed-methods study

BACKGROUND

Great disparities in immunization coverage exist in Pakistan between urban and rural areas. However, coverage estimates for large peri-urban slums in Sindh are largely unknown and implementation challenges remain unexplored. This study explores key supply- and demand-side immunization barriers in peri-urban slums, as well as strategies to address them. It also assesses immunization coverage in the target slums.

METHODS

Conducted in four peri-urban slums in Karachi, this mixed-methods study consists of a baseline cross-sectional coverage survey of a representative sample of 840 caregivers of children aged 12-23 months, and 155 in-depth interviews (IDIs) through purposive sampling of respondents (caregivers, community influencers and immunization staff). After identifying the barriers, a further six IDIs were then conducted with immunization policy-makers and policy influencers to determine strategies to address these barriers, resulting in the development of an original validated implementation framework for immunization in peri-urban slums. A thematic analysis approach was applied to qualitative data.

RESULTS

The survey revealed 49% of children were fully vaccinated, 43% were partially vaccinated and 8% were unvaccinated. Demand-side immunization barriers included household barriers, lack of knowledge and awareness, misconceptions and fears regarding vaccines and social and religious barriers. Supply-side barriers included underperformance of staff, inefficient utilization of funds, unreliable immunization and household data and interference of polio campaigns with immunization. The implementation framework's policy recommendations to address these barriers include: (1) improved human resource management; (2) staff training on counselling; (3) re-allocation of funds towards incentives, outreach, salaries and infrastructure; (4) a digital platform integrating birth registry and vaccination tracking systems for monitoring and reporting by frontline staff; (5) use of digital platform for immunization targets and generating dose reminders; and (6) mutual sharing of resources and data between the immunization, Lady Health Worker and polio programmes for improved coverage.

CONCLUSIONS

The implementation framework is underpinned by the study of uncharted immunization barriers in complex peri-urban slums, and can be used by implementers in Pakistan and other developing countries to improve immunization programmes in limited-resource settings, with possible application at a larger scale. In particular, a digital platform integrating vaccination tracking and birth registry data can be expanded for nationwide use.

Parental Awareness and Attitude about Childhood Immunization in Riyadh, Saudi Arabia: A Cross-Sectional Study

Parental beliefs about vaccination are one of the main factors in reaching high vaccination rates. This cross-sectional study aims to assess the awareness and attitudes regarding routine childhood immunization among Saudi parents in Riyadh, Saudi Arabia. This survey, with a pretested 18-item questionnaire, was conducted on parents having at least one child from Riyadh, Saudi Arabia, between 1 May 2019 and 1 November 2019. The validated questionnaire consisted of three sections; participants’ demographics, awareness, and attitude regarding the immunization of their children. In total, 1200 parents participated in the study, 883 (73.3%) of the parents scored a good knowledge of childhood immunization, and 93% knew that routine vaccination protects children from infectious diseases and their complications. Around 10% stated that immunization can cause autism. Only parents in age groups 30–39 and 40–49 were 1.76 (p < 0.05) times and 1.92 (p < 0.05) times, respectively, more likely to exhibit good knowledge. About 522 (43.6) of the parents attained a positive attitude toward immunization. Adherence to the immunization schedule was confirmed important by 93%, while 91% presumed that immunization keeps their children healthy. Additionally, immunization was perceived as important by 94% of parents and only 8% agreed that immunization is prohibited by religion. Females were 1.45 (p < 0.05) times more likely to exhibit positive attitudes than males. Parents have good knowledge and a positive attitude towards child immunization. However, parental education should be focused on the fact that religion supports immunization, and more awareness should be focused on the lack of correlation between autism and vaccination.

The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature

Addressing urban health challenges in low- and middle-income countries (LMICs) has been hampered by lack of evidence on effective mechanisms for delivering health services to the poor. The urban disadvantaged experience poor health outcomes (often worse than rural counterparts) and face service barriers. While community health workers (CHWs) have been extensively employed in rural communities to address inequities, little attention has been given to understanding the roles of CHWs in urban contexts. This study is the first to systematically examine urban CHW roles in LMICs. It aims to understand their roles vis-à-vis other health providers and raise considerations for informing future scope of practice and service delivery models. We developed a framework that presents seven key roles performed by urban CHWs and position these roles against a continuum of technical to political functions. Our scoping review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We included all peer-reviewed, CHW studies situated in urban/peri-urban, LMIC contexts. We identify roles (un)commonly performed by urban CHWs, present the range of evidence available on CHW effectiveness in performing each role and identify considerations for informing future roles. Of 856 articles, 160 met the inclusion criteria. Programmes spanned 34 LMICs. Studies most commonly reported evidence on CHWs roles related to health education, outreach and elements of direct service provision. We found little overlap in roles between CHWs and other providers, with some exceptions. Reported roles were biased towards home visiting and individual-capacity building, and not well-oriented to reach men/youth/working women, support community empowerment or link with social services. Urban-specific adaptations to roles, such as peer outreach to high-risk, stigmatized communities, were limited. Innovation in urban CHW roles and a better understanding of the unique opportunities presented by urban settings is needed to fully capitalize on their potential.

Strategies to increase uptake of maternal pertussis vaccination

INTRODUCTION

Pertussis is a highly contagious respiratory disease that results in disproportionate morbidity and mortality in infants who have yet to receive the primary diphtheria-tetanus-pertussis vaccine series. In the preceding decades numerous countries began to pursue either prenatal vaccination of pregnant women or postpartum vaccination of caregivers to protect infants. Despite proven benefit, maternal uptake of pertussis vaccine continues to remain suboptimal.

AREAS COVERED

Many studies have been conducted to address the suboptimal uptake of maternal pertussis vaccination. This systematic review was undertaken to systematically identify those studies, highlight the most successful strategies and find the knowledge gaps that need to be filled over the coming years to improve vaccine uptake. Twenty-five studies were identified from six different databases.

EXPERT OPINION

Five different interventions were shown to be successful in promoting uptake of pertussis vaccination: (1) standing orders, (2) opt-in orders, (3) provider education, (4) on-site vaccination and (5) interactive patient education. Three major knowledge gaps were also identified that need to be filled over the coming years: (1) lack of studies in low- and middle-income countries, (2) lack of studies targeting midwives and/or home birth and (3) lack of studies on the process of vaccine communication.

Age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community of Afar region, Ethiopia

Achieving and maintaining high-level immunization coverage is the priority of the health-care delivery system. However, any delay in receiving the vaccine leaves youngsters inadequately protected. Timely vaccination has scarcely been reported and given little attention in developing nations like Ethiopia, which hinders effective interventions. Therefore, this study aimed to assess age-appropriate vaccination practice and associated factors among mothers of children aged less than one year in the pastoral community. A community-based cross-sectional study has conducted among 340 mothers/caregivers of children aged less than one year in Samara-logia city administration. A systematic random sampling technique was employed to identify and enroll mothers-child paired. The logistic regression analysis had done to identify the factors associated with age-appropriate vaccination practice. The statistical association had measured, and a p-value < 0.05 was considered statistically significant. In this study, a total of 331 mothers/caregivers-child pairs participated with a response rate of 97.3%. The age-appropriate vaccination practice was 43.7% (95% CI, 38%, 49.5%). Mothers who had higher educational level (Adjusted odds ratio (AOR)) = AOR = 2.89, 95% CI (1.14, 7.3), antenatal care follow-up (AOR = 2.1, 95% CI (1.04, 4.1)), and had good knowledge on vaccination (AOR = 3.1, 95% CI (1.4, 6.78)) were associated with increased odds of age-appropriate vaccination practice.

The Impact of a Single Educational Lecture on the Vaccine Confidence among Pregnant Women and Young Mothers

Background: We investigated the impact of a single unstructured educational lecture about vaccinations on the vaccine confidence in volunteer participants. Methods: We conducted a survey-based study during a series of open meetings related to pregnancy and parenting. Before and after the pediatrician’s lecture related to vaccinations, listeners completed the visual analogue scales (VAS, 0–15 cm), evaluating (1) self-declared knowledge on vaccinations and (2) how they perceive the safety and efficacy of this preventive method. Results: In total, 484 women aged 30 ± 4 years participated in the lecture (pregnant = 68%; ≥1 children = 56%). Participants declared to have more comprehensive knowledge on preventive vaccinations and perceived vaccines to be safer and more useful (the role for the immunity) after vs. before the lecture (median VAS: 10.4 vs. 7.2, 10.8 vs. 8.7, and 11.0 vs. 10.4 cm, all p < 0.001). Importantly, the prevalence of vaccine-related adverse events was also assessed as being higher after the lecture (median VAS: 9.9 vs. 8.0 cm, p < 0.001). The increase in self-declared knowledge on vaccinations and perceived need for vaccinations (delta VAS—VAS after minus before the lecture, expressed as % of baseline) was lower among participants who rated the lecture less vs. more useful. Importantly, both participants who liked vs. did not like the lecture comparably rated vaccines safer after vs. before the lecture (delta VAS (median, interquartile range): 16% (0–39%) vs. 18% (2–42%), p = 0.39). Conclusions: An educational lecture on vaccinations positively impacts vaccine confidence in young adult women. Irrespective of the subjective rating of the lecture, all listeners perceived vaccinations to be safer after vs. before the speech.

Tetanus seroprotection in people living with HIV: Risk factors for seronegativity, evaluation of medical history and a rapid dipstick test

OBJECTIVES

Tetanus is a vaccine-preventable disease. Booster immunization is required in order to induce long-lived tetanus-toxoid (TT) specific antibody response. We investigated the prevalence and risk factors of TT seronegativity in a cohort of people living with HIV (PWH) in Belgium along with the respective performance of vaccine history and a rapid dipstick test (Tetanus Quick Stick ® or TQS) compared to ELISA testing.

METHODS

PWH were prospectively enrolled and answered a questionnaire. ELISA was performed on serum or plasma using a commercial kit. A TT antibody level ≥ 0.15 IU / mL was considered protective. The TQS test was performed on a limited number of subjects.

RESULTS

Three-hundred forty-four subjects were included. The prevalence of tetanus seroprotection was 84,9%. Median age was 46.7 and 68% were born outside Belgium. Antiretroviral therapy coverage was almost universal (98.5%). After multivariable analysis, two risk factors were independently associated with TT seronegativity: an education level equivalent or below than secondary school and being born outside Europe. Vaccine history was shown to be unreliable (sensitivity: 43.8%; specificity: 76.5%; positive predictive value: 91.4% and negative predictive value :19.3%). The correlation between vaccine history and tetanus seroprotection was low (kappa coefficient = 0.09). The TQS performances were good (sensitivity 86.4%, specificity 96.0%, positive predictive value 99.3%, negative predictive value 52.17%). The correlation between TQS and tetanus seroprotection was substantial (kappa coefficient = 0.61).

CONCLUSIONS

In this cohort of PWH with a high proportion of migrants, socio-demographic and educational factors were associated with TT seronegativity while HIV-related factors were not, indicating that vaccine information should be tailored to cultural and educational background. As vaccine history is not reliable, TQS could represent an efficient tool for screening of TT-seronegativity.

The use of a speaking book® to enhance vaccine knowledge among caregivers in The Gambia: A study using qualitative and quantitative methods

OBJECTIVES

To measure the usefulness of a Speaking Book (SB) as an educational tool for enhancing knowledge, understanding and recall of key vaccine-related information among caregivers in The Gambia, as well as its acceptability and relevance as a health promotion tool for caregivers and healthcare workers.

DESIGN AND SETTING

We developed a multimedia educational tool, the vaccine Speaking Book, which contained prerecorded information about vaccines provided in The Gambia's Expanded Programme on Immunization. Using qualitative and quantitative methods, we then conducted a sequential study assessing the use of this tool among caregivers andhealthcare workers in The Gambia.Participants200 caregivers attending primary healthcare centres in The Gambia for routine immunisation services for their infants, and 15 healthcare workers employed to provide immunisation services at these clinics.

OUTCOME MEASURES

We calculated the median knowledge scores on vaccine-related information obtained at baseline, 1-month and 3-month follow-up visits. Wilcoxon's matched-pairs signed-rank test was used to compare the difference in the median knowledge scores between baseline and 1-month, and between baseline and 3-month follow-up visits.

RESULTS

Of the 113 caregivers who participated, 104 (92%) completed all three study visits, 108 (95.6%) completed the baseline and 1-month follow-up visits, and 107 (94.7%) completed the baseline and 3-month follow-up visits. The median knowledge score increased from 6.0 (IQR 5.0-7.0) at baseline to 11.0 (IQR 8.0-14.0) at 1-month visit (p<0.001), and 15.0 (IQR 10.0-20.0) at 3-month visit (p<0.001). Qualitative results showed high acceptability and enthusiasm for the Speaking Book among both caregivers and healthcare workers. The Speaking Book was widely shared in the community and this facilitated communication with healthcare workers at the primary healthcare centres.

CONCLUSIONS

Context-specific and subject-specific Speaking Books are a useful communication and educational tool to increase caregiver vaccine knowledge in low/middle-income countries.

Critical Review of Data Analytics Techniques used in the Expanded Program on Immunization (EPI)

BACKGROUND

Immunization is a significant public health intervention to reduce child mortality and morbidity. However, its coverage, in spite of free accessibility, is still very low in developing countries. One of the primary reasons for this low coverage is the lack of analysis and proper utilization of immunization data at various healthcare facilities.

PURPOSE

In this paper, the existing machine learning-based data analytics techniques have been reviewed critically to highlight the gaps where this high potential data could be exploited in a meaningful manner.

RESULTS

It has been revealed from our review that the existing approaches use data analytics techniques without considering the complete complexity of Expanded Program on Immunization which includes the maintenance of cold chain systems, proper distribution of vaccine and quality of data captured at various healthcare facilities. Moreover, in developing countries, there is no centralized data repository where all data related to immunization is being gathered to perform analytics at various levels of granularities.

CONCLUSION

We believe that the existing non-centralized immunization data with the right set of machine learning and Artificial Intelligence-based techniques will not only improve the vaccination coverage but will also help in predicting the future trends and patterns of its coverage in different geographical locations.

Factor Structure and Equivalence of Maternal Resources for Care in Bangladesh, Vietnam, and Ethiopia

OBJECTIVES

Resources for care among women are crucial for children's growth and development. The objectives of this cross-sectional study were to determine if: (1) the factor structure of measures of maternal resources for care was comparable across countries and consistent with the theoretical constructs and (2) the measures showed equivalence across contexts.

METHODS

The study included 4400, 4029 and 2746 women from Bangladesh, Vietnam, and Ethiopia, respectively. The measures of resources for care were maternal education, knowledge, height, body mass index, mental well-being, financial autonomy, decision-making, employment, support in chores, and perceived support.

RESULTS

The factor analysis demonstrated that a two-factor solution best explained the structure of resources for care in all three countries. The first factor was associated with financial autonomy and employment in all three countries and with decision-making in two countries. The second factor was associated with education and knowledge in all three countries. The measures of resources for care had measurement equivalence across countries.

CONCLUSION FOR PRACTICE

Resources for care were structurally similar and measurement equivalent across countries and can be used for measurement in low- and middle-income countries. Additional work examining the structure and cross-context equivalence of resources for care in other settings is warranted.

What We Do Not Know About the Costs of Immunization Programs in Low- and Middle-Income Countries

• For many countries, there are limited data on the costs of running immunization services, and even less on the costs of increasing immunization coverage. • When considering different approaches for scaling up coverage, countries and funders need to understand the marginal change in coverage produced, costs of introduction, and how cost and coverage effects change depending on programmatic context. • Costing studies would benefit from improved, systematic reporting and leveraging ongoing program evaluation efforts to collect costing data. Long-term investments in the health system may allow for routine data collection and improved efficiency for budgeting and planning.

"Does Pakistan still have polio cases?": Exploring discussions on polio and polio vaccine in online news comments in Pakistan

INTRODUCTION

Polio, which is caused by poliovirus, is a contagious, potentially crippling, and deadly disease. Pakistan is one of the countries in which polio is still endemic in the 21st century. In 2019, 146 polio cases were reported across the country with some resulting in deaths. Following the spread of rumors insinuating that children were falling sick after receiving an anti-polio vaccine, a mob attacked and set fire to a small hospital in the Peshawar district in April 2019. The present study investigates readers' discussions that emerged from Dawn's online readers' comments on polio-related news stories in Pakistan.

METHODS

Using thematic analysis, we analyzed (N = 2216) comments made by readers in the polio-related news stories published on Dawn.com from January 1, 2012, to March 1, 2020.

RESULTS

Seven major themes emerged from the analysis of the comments: 1) reasons for and challenges resulting in the failure to eradicate polio; 2) proposed solutions and policy changes to eradicate polio; 3) misinformation; 4) criticism, frustration, and shame; 5) comparison of Pakistan to other countries; 6) the internet as a public sphere; 7) suffering, empathy, and appreciation. Overall, our findings suggested that commenters are knowledgeable about polio vaccines and consider polio a serious threat to public health in Pakistan.

CONCLUSION

Our study not only validated previous study findings such as reasons, challenges, and issues related to polio vaccination, but also found new challenges in online news sites concerning misinformation on polio and polio vaccination in Pakistan.

Covering the last mile for vaccination: Feasibility and acceptability of traditional birth attendant-based referral system in hard-to-reach areas in rural Pakistan

Background

Pakistan has a decent network of community-based workers including lady health workers (LHWs) and vaccinators. However, a major section of the population is not covered by LHWs/vaccinators, labeled here as hard-to-reach (HTR) areas, where immunization coverage is also considerably low. This study explored the feasibility of engagement of traditional birth attendants (TBAs) to improve EPI vaccination coverage in HTR areas in rural Sindh, Pakistan.

Methods

This implementation research was conducted in two sub-districts of Sukkur (a district in Sindh Province). In an HTR selected intervention arm, TBAs were trained for vaccination and monetary incentives were provided to counsel and refer mothers for vaccination. While LHWs covered areas in the adjacent sub-district were provided with refresher training for vaccination only without any monetary incentive, and were considered as control arm. Considering the inherent differences in intervention and comparison group (HTR intervention area being worse regarding infrastructure and access), between groups and within group change in knowledge of TBA/LHWs and vaccination coverage was assessed before and after the intervention. Furthermore, focus group discussions were conducted with vaccinators, TBAs and LHWs and in-depth interviews with supervisors of vaccinators.

Results

TBAs and LHWs' vaccine related knowledge increased significantly after training (pretest vs post test score: 10.5 to 15.4). The BCG coverage improved 74.1% (percentage change) in TBA arm. While completion of vaccination (ie, Penta-3 coverage) increased by 147% from baseline following the intervention. The TBAs, LHWs, vaccinators and their supervisors all welcomed the initiative and considered it as a feasible option.

Conclusions

Involvement of TBAs' to form a referral system has potential to improve vaccine coverage and completion in HTR areas in Pakistan. The system is acceptable to the population and implementation is feasible due to availability of TBAs. However, in order to sustain the initiative minimal incentive need to be provided to TBAs to improve the vaccination coverage. Compared to establishing the infrastructure in HTR the intervention seems less costly however, it requires formal cost-effective or cost-benefit analysis.

Complete basic childhood vaccination and associated factors among children aged 12-23 months in East Africa: a multilevel analysis of recent demographic and health surveys

Background

Complete childhood vaccination remains poor in Sub-Saharan Africa, despite major improvement in childhood vaccination coverage worldwide. Globally, an estimated 2.5 million children die annually from vaccine-preventable diseases. While studies are being conducted in different East African countries, there is limited evidence of complete basic childhood vaccinations and associated factors in East Africa among children aged 12–23 months. Therefore, this study aimed to investigate complete basic childhood vaccinations and associated factors among children aged 12–23 months in East Africa.

Methods

Based on the Demographic and Health Surveys (DHSs) of 12 East African countries (Burundi, Ethiopia, Comoros, Uganda, Rwanda, Tanzania, Mozambique, Madagascar, Zimbabwe, Kenya, Zambia, and Malawi), secondary data analysis was performed. The study included a total weighted sample of 18,811 children aged 12–23 months. The basic childhood vaccination coverage was presented using a bar graph. Multilevel binary logistic regression analysis was fitted for identifying significantly associated factors because the DHS has a hierarchical nature. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (−2LLR) were used for checking model fitness, and for model comparison. Variable with p-value ≤0.2 in the bi-variable multilevel analysis were considered for the multivariable analysis. In the multivariable multilevel analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the significance and strength of association with full vaccination.

Results

Complete basic childhood vaccination in East Africa was 69.21% (95% CI, 69.20, 69.21%). In the multivariable multilevel analysis; Mothers aged 25–34 years (AOR = 1.21, 95% CI: 1.10, 1.32), mothers aged 35 years and above (AOR = 1.50, 95% CI: 1.31, 1.71), maternal primary education (AOR = 1.26, 95% CI: 1.15, 1.38), maternal secondary education and above (AOR = 1.54, 95% CI: 1.36, 1.75), husband primary education (AOR = 1.25, 95% CI: 1.13, 1.39), husband secondary education and above (AOR = 1.24, 95% CI: 1.11, 1.40), media exposure (AOR = 1.23, 95% CI: 1.13, 1.33), birth interval of 24–48 months (AOR = 1.28, 95% CI: 1.15, 1.42), birth interval greater than 48 months (AOR = 1.35, 95% CI: 1.21, 1.50), having 1–3 ANC visit (AOR = 3.24, 95% CI: 2.78, 3.77), four and above ANC visit (AOR = 3.68, 95% CI: 3.17, 4.28), PNC visit (AOR = 1.34, 95% CI: 1.23, 1.47), health facility delivery (AOR = 1.48, 95% CI: 1.35, 1.62), large size at birth 1.09 (AOR = 1.09, 95% CI: 1.01, 1.19), being 4–6 births (AOR = 0.83, 95% CI: 0.75, 0.91), being above the sixth birth (AOR = 0.60, 95% CI: 0.52, 0.70), middle wealth index (AOR = 1.16, 95% CI: 1.06, 1.28), rich wealth index (AOR = 1.20, 95% CI: 1.09, 1.33), community poverty (AOR = 1.21, 95% CI: 1.11, 1.32) and country were significantly associated with complete childhood vaccination.

Conclusions

In East Africa, full basic childhood vaccine coverage remains a major public health concern with substantial differences across countries. Complete basic childhood vaccination was significantly associated with maternal age, maternal education, husband education, media exposure, preceding birth interval, number of ANC visits, PNC visits, place of delivery, child-size at birth, parity, wealth index, country, and community poverty. Public health interventions should therefore target children born to uneducated mothers and fathers, poor families, and those who have not used maternal health services to enhance full childhood vaccination to reduce the incidence of child mortality from vaccine-preventable diseases.

Engaging traditional barbers to identify and refer newborns for routine immunization services in Sokoto, Nigeria: a mixed methods evaluation

OBJECTIVES

This study evaluates the effectiveness of an intervention that engaged traditional barbers to inform parents about the importance of vaccination and then refer newborns for vaccination services.

METHODS

We conducted a pre-post quasi-experimental study (n = 2639) to evaluate changes in the coverage of three birth antigens among children aged 0-5 months in response to the intervention. We also conducted in-depth interviews and focus group discussions to assess the enabling factors and challenges associated with implementation.

RESULTS

We found mothers who received a yellow referral card from a traditional barber were two to three times more likely to vaccinate their children with the three birth antigens. Qualitative findings indicated that the intervention influenced parent's decision to vaccinate their newborn because the barbers were considered a trusted community advisor. Challenges stemmed from the low levels of literacy among community leaders and barbers that resulted in the need for continuous training, low-literacy training materials and supervision.

CONCLUSIONS

Efforts to increase vaccine coverage rates in northern Nigeria should consider expanding the role of traditional barbers to encourage parents to accept vaccines.

Can vaccination coverage be improved through reducing the missed opportunities for immunization? Results from the evaluation in Zhejiang province, east China

BACKGROUND

To evaluate the missed opportunities for vaccination (MOV) in Zhejiang province by using the global methodology from World Health Organization (WHO).

METHODS

Based on the WHO Planning Guide to Reduce Missed Opportunities for Vaccination (MOV) and Methodology for the Assessment of MOV, 33 health facilities from 11 cities in Zhejiang province were selected. For each health facility, exit investigations for 20 caregivers of children aged 0-23 months and knowledge, attitudes, and practices (KAP) surveys for 10 health workers was implemented. A MOV was determined based on the child's age on the date of investigation, eligibility for various vaccines. The prevalence of MOV was calculated and the risk factors of MOV were explored.

RESULTS

There were 660 completed exit investigations of caregivers of children aged 0-23 months and 330 health worker KAP investigations. Of the 658 children with documented vaccination records, 12.6% were still under-vaccinated. Among these under-vaccinated children, 54.2% still had a MOV. Children's age and their previous vaccination behavior, as well as caregivers' relationship to children and education level had a significant impact on the incidence of MOV.

CONCLUSION

The high proportions of visits with MOV in Zhejiang province suggested that interventions to reduce MOV in health service settings may be a potential quick win for improving coverage and equity. National immunization programs should explore the tailored efforts to improve health worker practices by making better use of existing health service contacts.

Expanding the use of community health workers in urban settings: a potential strategy for progress towards universal health coverage

Community health worker (CHW) programmes have been used for decades to improve access to health services in rural settings in low- and middle-income countries. With more than half of the world's population currently living in urban areas and this population expected to grow, equitable access to health services in urban areas is critically important. To understand the extent to which CHW programmes have been successfully deployed in low-income urban settings, we conducted a review of the literature between 2000 and 2018 to identify studies evaluating and describing CHW programmes implemented fully or partially in urban or peri-urban settings. We identified 32 peer-reviewed articles that met our inclusion criteria. Benefits have been documented in several urban settings in low- and middle-income countries including those to address TB/HIV, child health, maternal health and non-communicable diseases through a variety of study designs.

A data-driven framework for introducing predictive analytics into expanded program on immunization in Pakistan

BACKGROUND

Pakistan has a nationwide expanded program on immunization (EPI), yet vaccination coverage in Pakistan is quite low. Recently, an analytical model has been proposed to improve the coverage by identifying children who are most likely to miss any of the vaccines included in the immunization schedule, known as defaulters; however, a number of limitations remain unresolved in the previously proposed model. Firstly, it only classified children into two stages: defaulters and non-defaulters, considering all children at high risk of defaulting even if only one dose is missed. Secondly, there was no categorisation of high and low coverage areas for prioritised vaccination. The aim of this study was to propose a prediction framework for the accurate identification of defaulters.

METHODS

We have utilised a sample dataset extracted from the Pakistan Demographic and Health Survey (PDHS, 2017-2018). This contained 7153 data records with 19 demographic and socioeconomic attributes, which were used for defaulter prediction and the identification of association rules to understand the relation between demographics of the child and the vaccination status.

RESULTS

Using a multilayer perceptron (MLP) classifier, the proposed model achieved 98% accuracy and 0.994 for the area under the curve (AUC), to correctly identify the children who are likely to default from immunization series at different risk stages.

CONCLUSION

The proposed framework in this study is a step forward towards a data-driven approach and provides a set of machine learning techniques to utilise predictive analytics. Hence, this can reinforce immunization programs by expediting targeted action to reduce drop-outs.

Immunisation of children under 5 years: mothers' knowledge, attitude and practice in Alseir locality, Northern State, Sudan

Mothers are the major role players with regard to their children's immunisation. The aim of this study is to assess the knowledge, attitude and practice of mothers of children below 5 years of age with regard to immunisation in Northern State, Sudan. This was a cross-sectional survey which was conducted in three villages in 2016. All mothers having at least one child below the age of 5 years were included. Data were collected by interviews using a self-structured questionnaire. Descriptive statistics were displayed and chi-square test was used to assess associations. A total of 127 mothers of 191 children were included. The mean knowledge score about the names of vaccines/diseases prevented was 3.47 out of 10. The most correctly named vaccines by the mothers were measles (87.4%) and polio (86.6%), whereas the least ones were hepatitis (7.1%) and diphtheria (8.7%). The majority (99.2%) of the mothers had a positive attitude. The mean knowledge score about the timing of doses was 4.12 out of 5. The most correctly timed dose by the mothers was the dose at 6 weeks 'dose 1' (96.1%) and the least one was the dose at birth 'dose 0' (60.6%). About half (48.7%) of the children were completely immunised, 46% were only missing their 'dose 0', mostly because of closed vaccination units on the day of birth (73.6%), and 5.3% were incompletely immunised. Hospital delivery, availability of vaccination card and good socioeconomic status were associated with complete immunisation status, with p-values equal to 0.00, 0.00 and 0.03, respectively. Educating mothers about immunisation, increasing the days of immunisation and providing outreach services for home-delivered newborns are important interventions to increase the immunisation coverage.

Realist Synthesis of the International Theory and Evidence on Strategies to Improve Childhood Vaccination in Low- and Middle-Income Countries: Developing Strategies for the Nigerian Healthcare System

BACKGROUND

Childhood vaccination coverage rates in low- and middle-income countries (LMICs) vary significantly, with some countries achieving higher rates than others. Several attempts have been made in Nigeria to achieve universal vaccination coverage but with limited success. This study aimed to analyse strategies used to improve childhood vaccine access and uptake in LMICs in order to inform strategy development for the Nigerian healthcare system.

METHODS

A realist synthesis approach was adopted in order to elucidate the contexts and mechanisms wherewith these strategies achieved their aim (or not). Nine databases were searched for relevant articles and 27 articles were included in the study. Programme theories were generated from the included articles, and data extraction was carried out paying particular attention to context, mechanism and outcomes configurations.

RESULTS

Interventions used in LMICs to improve vaccination coverage were categorised as follows: communication/ educational, reminder-type, incentives, social mobilisation, provider-directed strategies, health service integration and multi-pronged strategies. The strategies that appeared most likely to be effective in the health contexts of contemporary Nigeria include communication and educational interventions; employing informal change agents, and; monitoring and evaluation to strengthen communication. The programme theories for the use of reminders, social mobilisation, staff training and supportive supervision were observed in practice, and these strategies were generally successful within some contexts. By contrast, the use of monetary incentives in Nigeria is not supported by the evidence, although further research and evaluation is required. The integration of other interventions with routine immunisation (RI) to improve uptake was more effective when the perceived value of the other program was high. Adoption of multipronged interventions for hard to reach communities was beneficial. However, caution should be exercised because of varying levels of published evidence in respect of each intervention type and a relative lack of the rich description required to conduct a full realist analysis.

CONCLUSION

This paper adds to the evidence base on the adaption of strategies to improve vaccine access and uptake to the context of LMICs.

ImmunizziAMO: A School-Based Field Trial to Teach New Generations the Importance of Vaccination through Games and to Fight Vaccine Hesitancy in Italy

BACKGROUND

Vaccines simulate the first contact with infectious agents and evoke the immunological response without causing the disease and its complications. High rates of immunization among the population guarantee the interruption of the transmission chain of infectious diseases. Therefore, the population should be aware of the value of vaccination and motivated. In order to implement the spread of a correct culture about these issues, schools were recognized as a privileged operational setting. The aim of this project was to transmit knowledge and convey educational messages on the importance of vaccines, through the use of games, in elementary school children, their families and teachers.

MATERIALS AND METHODS

A field trial study was implemented between April and October 2019. Sample size calculations highlighted the need to recruit at least 136 students in the schools. The intervention involved 10 classes (five first grade and five s grade classes) and was structured in frontal teaching sessions and gaming sessions. Knowledge was assessed comparing the results of a questionnaire administered before and after the intervention. The questionnaires referred to the following items: dangerousness of bacteria and viruses; capability of defending from microorganisms; the role of antibodies; functioning of the vaccine in a child; type of disease for which a vaccine is efficacious; duration of a vaccine; mother- child transmission of antibodies; herd immunity.

RESULTS

143 children participated in all the phases of the study. The comparison between the scores at the beginning and end of the intervention showed a significant increase in the knowledge about vaccines and immunity. The mean knowledge score arose from 3.52 (SD = 1.67) to 5.97 (SD = 1.81).

CONCLUSIONS

This study suggests that the use of games in an elementary school effectively increase the knowledge related to the important topic of vaccination starting at childhood.

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

BACKGROUND

Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later.

METHODS

Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia.

RESULTS

Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1.

CONCLUSIONS

We report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications.

TRIAL REGISTRATION

Not Applicable.

Age-appropriate vaccination coverage and its determinants for the polio containing vaccine 1-3 and measles-containing vaccine doses in Zhejiang province, China: A community-based cross-sectional study

Background: This study aimed to evaluate the age-appropriate coverage and its associated risk factors for the primary vaccination of Polio containing vaccine (PCV) and measles-containing vaccine (MCV) through the secondary use of the 2018 Zhejiang provincial coverage survey among children aged 12-23 months. Methods: Data were collected through structured pre-tested Chinese version questionnaire by face-to-face interview among 770 mothers whose children aged 12-23 months. Age-appropriate vaccination coverage was measured using Chinese vaccination schedule recommendation. Bivariate and multivariate logistic regression models were adopted to identify determinants of the age-inappropriate vaccination. Results: The age-appropriate vaccination coverage of PCV1, PCV2, PCV3, and MCV was 88.8%, 80.8%, 73.6%, and 75.7%, respectively. The risk factors associated with the age-inappropriate vaccination of PCV 1-3 dose and MCV included child's gender, birthplace, living area, maternal education level, immigration status, monthly household income, participation of the pregnant women's seminar, antenatal care follow-up, knowledge on vaccination. Conclusion: The proportions of age-appropriate vaccination coverage were low compared with the up-to-date coverage. Modifiable factors were associated with age-inappropriate vaccinations. Vaccination interventions should consider identified modifiable factors to improve age-appropriate vaccination coverage.

Why Have Immunization Efforts in Pakistan Failed to Achieve Global Standards of Vaccination Uptake and Infectious Disease Control?

Immunization is one of the most successful public health initiatives in recent times. It is, therefore, worrying to learn the level of under-vaccination in Pakistan. Diseases that have been successfully eliminated through the aid of vaccination in other countries have not been eliminated in Pakistan. The reasons for this vary and show the uniqueness of the economic, healthcare and environmental landscape of Pakistan, through which public health programmes need to be implemented. The “Expanded Programme of Immunization” (EPI) is the main programme through which routine immunization is provided to the public. Within Pakistan, it has encountered many problems since its inception. This includes logistical obstacles, inefficient health worker attitudes, parental and female awareness, and education, the influence of religious community leaders and the complications that accompany conflict. When compared to globally standardised targets for immunization, Pakistan is trailing behind. Not achieving these targets is worrying from both a global perspective and within the national healthcare landscape of Pakistan. Research is necessary to bring together findings on the failings of routine immunization and polio campaigns; there are many intersecting factors that global health bodies and the Department of Health in Pakistan must address in order to relieve the burden of vaccine-preventable diseases (VPDs).

Awareness Among Parents About Pneumococcal Conjugate Vaccine in Routine Immunization Program to Prevent Pneumococcal Pneumonia in Bangladesh

Introduction

This study was conducted in two purposively selected slums of Dhaka to assess parents’ awareness of pneumococcal conjugate vaccine (PCV) in reducing the occurrence of death due to pneumococcal pneumonia.

Methods

Using a semi-structured questionnaire, face-to-face interviews were conducted with 150 parents. Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 20 (IBM Corp., Armonk, NY) and Chi-square (χ2) test performed to determine associations.

Results

About 35% of parents were found to be aware of PCV; of them, 92.5% were informed by health service providers, and 81.1% mentioned benefits of PCV. Most parents were unaware of the PCV vaccination status of children, and no significant association was found between vaccination status and parents’ socioeconomic status. Aware parents vaccinated their children, and the association of awareness with vaccination status was statistically significant for PCV-1 (P = 0.04) and PCV-2 (P < 0.001). Although 7.4% of parents did not vaccinate their child with PCV-3 due to a child’s sickness or other priorities in household work, the association was significant (P = 0.01).

Conclusion

Strengthened efforts by health service providers, prioritizing dissemination of key messages on PCV, its benefits, and side-effects, can motivate parents and reduce dropout rates.

Applying a governance barometer to vaccine delivery systems: Lessons from a rural district of Pakistan

INTRODUCTION

Weak vaccine delivery systems in countries off-track for routine immunization targets, need in-depth evidence on system level barriers to be critically resourced and monitored. We applied a Balanced Score Card (BSC) approach in a rural underserved district of Pakistan to (i) identify critical areas needing support in the government vaccine delivery system; and (ii) for benchmarking improvements in the vaccine delivery system.

METHODOLOGY

BSC was developed drawing on desk review, government consultations and field testing. 45 immunization indicators were finalized across 8 domains: human resource; vaccine supply; safe vaccination practice; cold chain maintenance; outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Data were collected through health facility assessments, client exit interviews and household vaccination assessment. A composite score was calculated for each domain and banded into unsatisfactory, borderline and satisfactory categories. 5 lowest ranking domains were targeted for 2 years of health systems strengthening (HSS) interventions. Post-intervention assessment tracked progress.

RESULTS

The district obtained a cumulative score of 51% (unsatisfactory) at pre-intervention and improved to 82% (satisfactory) at post-intervention. At pre-intervention, 4 domains scored satisfactory and 4 scored unsatisfactory. Unsatisfactory scores were received for: outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Post intervention 6 of 8 domains scored satisfactory and 2 moved from unsatisfactory to borderline. Highest percentage point (pp) improvements were seen in outreach preparedness (53 pp, p = 0.01), EPI supervision (52 pp, p = 0.01) and verified vaccination volume (46 pp, p = 0.02). 3 domains that were not intervened through HSS interventions had minimal change in scoring - cold chain maintenance (6 pp), safe vaccination practice (12 pp) and vaccine supply (11 pp).

CONCLUSION

BSC served to prioritize interventions towards critical unmet needs for vaccine delivery in the district health system and particularly helped to improve outreach preparedness, EPI supervision and verified vaccination volume.

Systematic review of the costs and effectiveness of interventions to increase infant vaccination coverage in low- and middle-income countries

Background

In recent years, several large studies have assessed the costs of national infant immunization programs, and the results of these studies are used to support planning and budgeting in low- and middle-income countries. However, few studies have addressed the costs and cost-effectiveness of interventions to improve immunization coverage, despite this being a major focus of policy attention. Without this information, countries and international stakeholders have little objective evidence on the efficiency of competing interventions for improving coverage.

Methods

We conducted a systematic literature review on the costs and cost-effectiveness of interventions to improve immunization coverage in low- and middle-income countries, including both published and unpublished reports. We evaluated the quality of included studies and extracted data on costs and incremental coverage. Where possible, we calculated incremental cost-effectiveness ratios (ICERs) to describe the efficiency of each intervention in increasing coverage.

Results

A total of 14 out of 41 full text articles reviewed met criteria for inclusion in the final review. Interventions for increasing immunization coverage included demand generation, modified delivery approaches, cash transfer programs, health systems strengthening, and novel technology usage. We observed substantial heterogeneity in costing methods and incompleteness of cost and coverage reporting. Most studies reported increases in coverage following the interventions, with coverage increasing by an average of 23 percentage points post-intervention across studies. ICERs ranged from $0.66 to $161.95 per child vaccinated in 2017 USD. We did not conduct a meta-analysis given the small number of estimates and variety of interventions included.

Conclusions

There is little quantitative evidence on the costs and cost-effectiveness of interventions for improving immunization coverage, despite this being a major objective for national immunization programs. Efforts to improve the level of costing evidence—such as by integrating cost analysis within implementation studies and trials of immunization scale up—could allow programs to better allocate resources for coverage improvement. Greater adoption of standardized cost reporting methods would also enable the synthesis and use of cost data.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4468-4) contains supplementary material, which is available to authorized users.

Epidemiology and risk factors of transfusion transmitted infections in thalassemia major: a multicenter study in Pakistan

Background

Blood transfusion-transmitted infections in individuals suffering from beta-thalassemia have been reported in Pakistan, but the information on their sociodemographic and clinical determinants is lacking. This study aims to describe the prevalence, as well as the factors, contributing in blood transfusion-transmitted infections.

Method

Between December 2011 and December 2013, in a non-probable sampling, 350 thalassemia patients were recruited in Lahore, Multan, Karachi and Peshawar, Pakistan. Subjects were screened for transfusion-transmitted infections.

Results

A seropositive rate of 36.5% was observed; males (94, 73.4%) and females (34, 26.6%). Among several risk factors associated with transfusion-transmitted infections, province (p = 0.001), gender (p = 0.003), age (p < 0.03), education (p < 0.00), degree of consanguinity (p = 0.05), age at fetal blood test (p = 0.005), fetal hemoglobin levels (p = 0.005), death due to thalassemia (p = 0.001) and iron-related complications (p = 0.04) showed significant correlation. Participants with an age >10 years were significantly more prone to seropositivity than those aged ≤10 years. Moreover, the ferritin level was also significantly higher in those aged >10 years than in those ≤10 years. It was observed that males had a higher seroprevalence rate (94, 73.4%) than females (34, 26.6%). The most prevalent transfusion-transmitted infections was the hepatitis C virus, with 115 cases (89.8%).

Conclusion

A high prevalence rate of HCV in subjects with transfusion-dependent thalassemia is linked with insufficient facilities, poor management and compromised socioeconomic status. Therefore, more multicenter studies covering cities from different regions of the country are needed in order to develop preventive measurements at the regional and national level.

System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan

Background

Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme’s performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme’s insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities.

Methods

We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO’s six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes.

Results

The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines.

Conclusions

The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0452-z) contains supplementary material, which is available to authorized users.

Parent-targeted postnatal educational interventions in low and middle-income countries: A scoping review and critical analysis

OBJECTIVES

To identify and map existing postnatal educational interventions targeting parents in low and middle-income countries. A secondary objective is to conduct a critical analysis of the strengths and limitations of the educational strategies used for parent-targeted postnatal education. Design & data sources: Using scoping review methodology, MedLine, CINAHL, and SCOPUS were searched in October 2017.

REVIEW METHODS

All studies published after 2000 reporting on educational interventions that targeted parents from the period of birth to 6 weeks postnatally in low and middle-income countries were included. Studies were excluded if they targeted healthcare professionals or were community interventions that spanned antenatal to postnatal care. Title, abstract and full-text screening was conducted by two reviewers.

RESULTS

We initially identified 9284 articles with 77 articles included after title, abstract and full-text screening. Most of the studies were quantitative (94%) with over half published after 2014. Most studies (61%) targeted a single newborn care education intervention, of which 75% targeted breastfeeding. Interventions used on average three different methods of implementation (e.g., verbal, written information, counselling). Interventions were provided in the hospital (76%), at home (23%), at a clinic/hospital (8%), and/or virtually through an eHealth intervention, including phone or text messages (12%). Maternal outcomes primarily included knowledge, self-efficacy, anxiety and stress while newborn outcomes primarily included exclusive breastfeeding, weight gain at follow-up, and morbidities. Positive changes were found to occur for reported maternal outcomes (89%) and newborn outcomes (56%).

CONCLUSIONS

Parent-targeted education varied in terms of educational topics covered, method and location of intervention, and outcomes examined. While the best strategies of implementing postnatal education interventions to parents in low and middle-income countries is yet to be determined, evidence suggests that current interventions had a positive impact on parents' outcomes using a combined approach. Further work is needed to evaluate the impact on newborn outcomes and to identify the most effective methods and timing of the interventions.

Achieving the end game: employing "vaccine diplomacy" to eradicate polio in Pakistan

Background

On April 28, 2014, the World Health Organization (WHO) declared polio a “Public Health Emergency of International Concern” (PHIC) under the authority of the International Health Regulations. Although polio has been eradicated from nearly every nation on earth, Pakistan is one of three countries where wild polio and vaccine-derived polio strains remain, thwarting global eradication efforts.

Aims

Polio eradication progress is complicated by security and conflict issues at the border area between Pakistan and Afghanistan. In addition to security issues, other critical challenges, such as maintaining cold supply chain for vaccines, active and sentinel surveillance, false beliefs about vaccines, distrust of healthcare workers, and accessibility to conflict areas due to terrorist activities, all play a role in the continued persistence of Polio. In response to these challenges, we assess the local and international policy environment and its impact on polio eradication in Pakistan.

Findings

Based on our analysis of existing barriers and challenges associated with polio eradication in Pakistan, this study discusses why employing “vaccine diplomacy” represents a key policy and advocacy strategic approach to achieve the overall end game of polio eradication. Specifically, we identify a set of concrete public health, international development, and diplomatic and policy recommendations that can act synergistically under the umbrella of health and vaccine diplomacy to finally put an end to polio.

Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data

BACKGROUND

Pakistan has a high burden of newborn mortality, which would be significantly preventable through appropriate routine immunization. The purpose of this study was to measure the basic timely childhood immunization coverage and to identify determinants of factors influencing childhood immunization coverage in Sindh, Pakistan.

METHODS

Data from Maternal and Child Health Program Indicator Survey 2013-2014 which was conducted in Sindh province of Pakistan was used. Outcome measure was full coverage of the basic immunization schedule from child's vaccination card. The association of receiving basic immunization with demographic factors, socioeconomic status, mother and child health information sources, and perinatal care factors were tested by binary logistic regression.

RESULTS

Among 2,253 children, 1,156 (51.3%) received age-based full basic immunization. The basic immunization rates were 69.1% for under five weeks old, 38.3% for six to nine weeks, 18.8% for 10-13 weeks, 44.0% for 14 weeks-eight months, 60.4% for nine to 11 months, and 59.1% for over one year. Child's age, number of living children, parents' education level, wealth, the source of mother and child health information, number of antenatal care, and assistance during delivery were associated with completing basic immunization.

CONCLUSIONS

The overall full basic immunization coverage in Pakistan was still low. Policy makers should identify children at risk of low immunization coverage and obstacles of receiving antenatal care, implement educational interventions targeting on less educated parents, and conduct mass immunization campaigns for timely and complete immunization.