There is still a substantial knowledge gap on how gender mediates child health in general, and child immunisation outcomes in particular. Similarly, implementation of interventions to mitigate gender inequities that hinder children from being vaccinated requires additional perspectives and research. We adopt an intersectional approach to gender and delve into the social ecology of implementation, to show how gender inequities and their connection with immunisation are grounded in the interplay between individual, household, community and system factors. We show how an ecological model can be used as an overarching framework to support more precise identification of the mechanisms causing gender inequity and their structural complexity, to identify suitable change agents and interventions that target the underlying causes of marginalisation, and to ensure outcomes are relevant within specific population groups.
BACKGROUND: To assess the effect of health information on immunisation uptake in rural India, we conducted an individually randomised controlled trial of health information messages targeting the mothers of unvaccinated or incompletely vaccinated children through home visits in rural Uttar Pradesh, India. METHODS AND FINDINGS: The study tested a brief intervention that provided mothers face-to-face with information on the benefits of the tetanus vaccine. Participants were 722 mothers of children aged 0-36 months who had not received 3 doses of diphtheria-pertussis-tetanus (DPT) vaccine (DPT3). Mothers were randomly assigned in a ratio of 1:1:1 to 1 of 3 study arms: mothers in the first treatment group received information framed as a gain (e.g., the child is less likely to get tetanus and more likely to be healthy if vaccinated), mothers in the second treatment group received information framed in terms of a loss (e.g., the child is more likely to get tetanus and suffer ill health if not vaccinated), and the third arm acted as a control group, with no information given to the mother. Surveys were conducted at baseline (September 2015) and after the intervention (April 2016). The primary outcome was the proportion of children who had received DPT3 measured after 7 months of follow-up. The analysis was by intention to treat. A total of 16 (2.2%) participants were lost to follow-up. The coverage of DPT3 was 28% in the control group and 43% in the pooled information groups, giving a risk difference of 15 percentage points (95% CI: 7% to 22%, p < 0.001) and a relative risk of 1.52 (95% CI: 1.2 to 1.9, p < 0.001). The information intervention increased the rate of measles vaccination by 22 percentage points (risk difference: 22%, 95% CI: 14% to 30%, p < 0.001; relative risk: 1.53, 95% CI: 1.29 to 1.80) and the rate of full immunisation by 14 percentage points (risk difference: 14%, 95% CI: 8% to 21%, p < 0.001; relative risk: 1.72, 95% CI: 1.29 to 2.29). It had a large positive effect on knowledge of the causes, symptoms, and prevention of tetanus but no effect on perceptions of vaccine efficacy. There was no difference in the proportion of children with DPT3 between the group that received information framed as a loss and the group that received information framed as a gain (risk difference: 4%, 95% CI: -5% to 13%; p = 0.352; relative risk: 1.11, 95% CI: 0.90 to 1.36). The cost per disability-adjusted life year averted of providing information was US$186, making the intervention highly cost-effective with respect to the WHO-recommended threshold of once the gross domestic product per capita (US$793 in the case of Uttar Pradesh). Key study limitations include the modest sample size for this trial, limiting power to detect small differences in the framing of information, and the potential for contamination among households. CONCLUSIONS: Providing mothers of unvaccinated/incompletely vaccinated children with information on tetanus and the benefits of DPT vaccination substantially increased immunisation coverage and was highly cost-effective. The framing of the health information message did not appear to matter. TRIAL REGISTRATION: The trial is registered with ISRCTN, number ISRCTN84560580.
Timothy Powell‐Jackson, Camilla Fabbri, Varun Dutt et al.
Background: Missed immunisation (MI) may contribute to low immunisation coverage in diverse settings, especially developing countries. Receipt of vaccines at the recommended ages and intervals will ensure that children are adequately protected from target diseases at all times. Immunisation reminder and recall (RR) systems are cost-effective methods of improving adherence to recommended immunisation schedules. This study, therefore, determined the effect of immunisation reminders and recalls on reducing missed immunisations in Abakaliki. Materials and Methods: This is a quasi-experimental study conducted among caregivers of infants in rural health facilities in Abakaliki. Mile-Four and St. Vincent hospitals located in Ebonyi and Izzi Local Government Areas (LGA) respectively in Ebonyi State were selected purposively. Mile-Four was assigned intervention group and St. Vincent as control group. The sample size was determined using the formula for comparing two proportions. Caregiver-child pair was recruited during the infants’ BCG or Pentavalent vaccines 1 immunisation visit and followed till the final scheduled immunisation visit for each child. Data was collected using a questionnaire, proforma and checklist. Statistical Package for Social Science (SPSS) version 22.0 was used for analysis. Ethical approval was obtained from the Research and Ethics Committee (REC) of the Federal Teaching Hospital Abakaliki (FETHA). Results: A greater proportion of respondents in the intervention group (8.3%) missed vaccination at the 6th and 10th weeks when compared with the 4.1% and 6.9% for the above mentioned weeks respectively in the control group. In the control group, a greater proportion (22.1%) missed vaccination than the intervention group (8.9%) at the 14th week, a difference in the proportion that was significant (p=0.04). Relative to female caregivers, male caregivers are 6.2 times more likely to miss immunisation in the intervention group. They are 2.3 times more likely to miss immunisation than the female ones in the control group. Those at older age (≥30 years) are 1.2 times more likely to miss immunisation than those of younger age group. Conclusion: Mobile phone reminders and recall has proven effective in reducing childhood missed immunisations and non-compliance in Abakaliki. Implementation of immunisation reminders and recall systems is therefore recommended in immunisation clinics in developing countries especially in Nigeria for immunisation timeliness and completion.
Nelson Chibueze Eze, Benedict Ndubueze Azuogu, Ijeoma Okoronkwo
Introduction: This study aimed to determine the effects of parental short message service (SMS) reminders on infant immunisation coverage, timeliness and barriers and evaluate the effects of sex on immunisation outcomes in Maiduguri, Borno State, Nigeria. Methods: This two-arm quasi-experimental study was conducted in two primary healthcare facilities selected using simple random sampling with opaque envelopes. A total of 524 participants were enrolled using purposive sampling. Data were statistically analysed using the Statistical Package for the Social Sciences version 28 with repeated-measures logistic regression analysis, the Z test for Poisson rates and the Wilcoxon signed-rank test. Results: The parental SMS reminders significantly improved the immunisation coverage, as reported by 69 (26.3%) (P=0.001, 95% confidence interval [CI] = 12.2-40.5), 117 (44.7%) (P=0.001, 95% CI=32.6-56.9) and 116 (44.3%) participants (P=0.001, 95% CI=34.2-54.4) for the 6th-, 10th- and 14th-week schedules, respectively. Compared to mothers' involvement, fathers' involvement did not significantly affect the immunisation coverage (B=0.158, P=0.311, 95% CI=-0.148-0.464). With regard to the immunisation timeliness, the parental SMS reminders yielded a significant effect for the 6th-, 10th- and 14th-week schedules (P=0.001, 95% CI=25.9-46.7; P=0.001, 95% CI=24.2-43.0; and P=0.001, 95% CI=21.1-36.9, respectively). Compared to mothers' involvement, fathers' involvement significantly influenced the immunisation timeliness (B=0.298, P=0.038, 95% CI=0.016-0.579). Lastly, the parental SMS reminders significantly reduced the barriers to immunisation, with a P-value of 0.001. Conclusion: Parental SMS reminders can significantly improve immunisation outcomes in Nigeria.
Dathini Hamina, Siti Khuzaimah Ahmad Sharoni, Kever Robert
OBJECTIVE: Senegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared with other low-income and lower-middle income countries. Understanding factors associated with historical changes in childhood vaccine coverage in Senegal, as well as heterogeneities across its 14 regions, can highlight effective practices that might be adapted to improve vaccine coverage elsewhere. DESIGN: Childhood vaccination coverage rates, demographic information and health system characteristics were identified from Senegal's Demographic and Health Surveys (DHS) and Senegal national reports for years 2005-2019. Multivariate logistic and linear regression analyses were performed to determine statistical associations of demographic and health system characteristics with respect to childhood vaccination coverage rates. SETTING: The 14 administrative regions of Senegal were chosen for analysis. PARTICIPANTS: DHS women's survey respondents with living children aged 12-23 months for survey years 2005-2019. OUTCOME MEASURES: Immunisation with the third dose of the diphtheria-tetanus-pertussis vaccine (DTP3), widely used as a proxy for estimating immunisation coverage levels and the retention of children in the vaccine programme. RESULTS: Factors associated with childhood vaccination coverage include urban residence (β=0.61, p=0.0157), female literacy (β=1.11, p=0.0007), skilled prenatal care (β=1.80, p<0.0001) and self-reported ease of access to care when sick, considering travel distance to a healthcare facility (β=-0.70, p=0.0009) and concerns over travelling alone (β=-1.08, p<0.0001). Higher coverage with less variability over time was reported in urban areas near the capital and the coast (p=0.076), with increased coverage in recent years in more rural and landlocked areas. CONCLUSIONS: Childhood vaccination was more likely among children whose mothers had higher literacy, received skilled prenatal care and had perceived ease of access to care when sick. Overall, vaccination coverage is high in Senegal and disparities in coverage between regions have decreased significantly in recent years.
Hannah K. Smalley, Francisco Castillo-Zunino, Pınar Keskinocak et al.
Background/Objectives: Routine immunisation (RI) coverage declines during the COVID-19 pandemic, from 2020 to 2022, are well-reported. With the declared end to the Public Health Emergency of International Concern in May 2023, and the end of most non-pharmaceutical interventions that were introduced to prevent or minimise COVID-19 spread, we (I) assess whether routine immunisation coverage has rebounded to pre-pandemic trends, and (II) seek to identify factors that help predict whether country performance has exceeded, maintained, or declined compared to expectations (based on time-series forecasting). Methods: We quantify global and country-level routine immunisation diphtheria-tetanus-pertussis (DTP) coverage trends post-pandemic (2023) compared to pre-pandemic trends using time-series forecasting across 190 countries. We used Discriminant Analysis of Principal Components and Random Forests to identify relevant predictors of country-level coverage performance, including 28 indicators of health system strength, health workforce, country income, pandemic containment, economic, and health policies, and demographic aspects. Results: We show that mean global DTP third-dose coverage levels remained on average 2.7% [95% confidence intervals: 1.1% - 4.3%] lower than expected in 2023. However, once accounting for temporal demographic changes, we find that this translates to the total number of immunised children almost reverting to expected levels, owing to decreasing fertility reducing global-level immunisation target populations. At a country-level, notable disruption remaining in over 30 countries (17.6% of countries below expectations, 81.6 within expected ranges, and 1.7% above expectations). Neither predictive method performed well at identifying factors associated with coverage disruptions. Conclusions: Despite the end of COVID-19 pandemic measures, RI remains below expectations in 20% of countries. No clear drivers of this continued disruption were identified. Further research is required to inform recovery efforts and prevent future epidemic and pandemic disruptions to routine health services.
BACKGROUND: Despite the successful implementation of the Expanded Programme on Immunization (EPI) for the past three decades, Vietnam has recently witnessed outbreaks of vaccine-preventable diseases, indicating a potential gap in immunisation uptake across population groups. Daklak province is a rural highland area, home to 46 ethnic groups with complicated socio-economic backgrounds. The province reported sporadic outbreaks of vaccine-preventable diseases and low vaccine uptake in some remote low-socioeconomic groups despite a high record of provincial coverage. Within this context, we aim to explore the perspectives and experiences of ethnic minority communities related to EPI vaccination and how socio-economic and contextual factors influence such views and practices in Daklak province. METHODS: We used qualitative data collected between 2018 and 2022 from in-depth interviews, focus group discussions, and participant observation with different stakeholders of the EPI programme. The study took place in nine districts across 25 communes of the province with different socio-economic characteristics and vaccination patterns. We invited mothers who were the primary caregivers taking children to vaccination and healthcare workers who were directly involved in vaccination delivery in the local areas. We incorporated the SAGE's public health framework of the vaccine hesitancy matrix and the anthropological concept of structural vulnerability to discern the structural roots of vaccine attitudes and behaviours of the community. RESULTS: Overall, the research shows that views and behaviours related to children's vaccination are complicatedly influenced by multi-ecological factors. In particular, we found a critical influence of socioeconomic conditions and social networks on the community's vaccine acceptance and uptake. The community's interaction with the health system and the government through local healthcare workers was also critical in fostering community trust towards vaccines and the EPI programme. In addition, we revealed that the issues with non-compliance to the EPI in the lowest-uptake communities were structurally related to their economic vulnerabilities and social marginalisation. CONCLUSIONS: These findings implicate the need for tailoring public health and socioeconomic interventions to enhance vaccination opportunities in the marginalised groups.
BACKGROUND: As India already missed maternal and child health related millennium development goals, the maternal and child health outcomes are a matter of concern to achieve sustainable development goals (SDGs). This study is focused to assess the gap in coverage and inequality of various reproductive, maternal, neonatal and child health (RMNCH) indicators in 640 districts of India, using data from most recent round of National Family Health Survey. METHODS: A composite index named Coverage Gap Index (CGI) was calculated, as the weighted average of eight preventive maternal and child care interventions at different administrative levels. Bivariate and spatial analysis were used to understand the geographical diversity and spatial clustering in districts of India. A socio-economic development index (SDI) was also derived and used to assess the interlinkages between CGI and development. The ratio method was used to assess the socio-economic inequality in CGI and its component at the national level. RESULTS: The average national CGI was 26.23% with the lowest in Kerala (10.48%) and highest in Nagaland (55.07%). Almost half of the Indian districts had CGI above the national average and mainly concentrated in high focus states and north-eastern part. From the geospatial analysis of CGI, 122 districts formed hotspots and 164 districts were in cold spot. The poorest households had 2.5 times higher CGI in comparison to the richest households and rural households have 1.5 times higher CGI as compared to urban households. CONCLUSION: Evidence from the study suggests that many districts in India are lagging in terms of CGI and prioritize to achieve the desired level of maternal and child health outcomes. Efforts are needed to reduce the CGI among the poorest and rural resident which may curtail the inequality.
Vitamin A deficiency is one of the most important causes of preventable childhood blindness. The main objective of this study was to identify the coverage of vitamin A prophylaxis programme and its determinants. Descriptive survey research design was adopted for the study. The study was conducted on 113 mothers and their children under five years of age residing in Kozhikode Corporation, Kerala. The subjects were selected using convenience sampling. Direct interview of the subjects was conducted to identify the determinants of vitamin A prophylaxis programme. Tools used were semi structured questionnaire and checklist. The data obtained from the subjects was verified using immunisation card. The study findings showed that more than half of the children (57%) have partial coverage, while 35 percentage of subjects had full coverage and about 8 percentage of subjects had no coverage of vitamin A prophylaxis programme. There is significant association between age of the child and vitamin A prophylaxis programme (p<0.001). The most important facilitating factors for vitamin A prophylaxis were; availability of vitamin A prophylaxis at Government hospital/ primary health centre/ Subcentre, vitamin A given along with the other doses of immunization, reminder or recall message from health workers. The most important barriers of vitamin A prophylaxis in this study were, lack of awareness about the nine doses of vitamin A, unavailability of vitamin A prophylaxis from the immunisation centre, fear of going out owing to covid 19 pandemic and absence of vitamin A prophylaxis facility nearby.
Childhood vaccinations are among the most cost-effective health interventions. Yet, in India, where immunisation services are widely available free of charge, a substantial proportion of children remain unvaccinated. We revisit households 30 months after a randomised experiment of a health information intervention designed to educate mothers on the benefits of child vaccination in Uttar Pradesh, India. We find that the large short-term effects on the uptake of diphtheria-pertussis-tetanus and measles vaccination were sustained at 30 months, suggesting the intervention did not simply bring forward vaccinations. We apply causal forests and find that the intervention increased vaccination uptake, but that there was substantial variation in the magnitude of the estimated effects. We conclude that characterising those who benefited most and conversely those who benefited least provides policy-makers with insights on how the intervention worked, and how the targeting of households could be improved.
Stephen O’Neill, Richard Grieve, Kultar Singh et al.
