Interventions for Improving Coverage of Childhood Immunization in Low and Middle-Income Countries

Immunization is a very significant strategy used in the public health to improve the survival of children by combating some key illnesses that endanger the lives of children as well as acting as a platform for other services. It has however been noticed that every year, large numbers of children do not receive the completed vaccine series as recommended in the various routine schedules of immunization in every country. This unfortunate phenomenon has majorly been observed in middle income and low income states across the globe. The main objective of this review is to conduct an evaluation of how effective are the strategies of intervention in boosting and sustaining high immunization of children in the low and middle income countries. The review evaluates impact the various strategies that have been put in place have on the adherence to the immunization schedule. The review also seeks to answer the question on whether the strategies put in place actually work and if in the end, the intended purpose if fully achieved. The interventions covered in the review are meant to address the problem of low childhood immunization especially in the middle and low income countries.

As cited from WHO (2012) in the review, the vaccination coverage of DTP3 stood at 5% globally. The percentage grew gradually and by 1980, it stood at 17%. The low immunization coverage prompted the WHO to partner with UNICEF to drum up a global campaign which aimed at the universal immunization of children and to push the immunization coverage to at least 80% by the year 1990. It was however later noted that the progress was quite slow especially in the middle and low income countries. As cited from UNICEF (2015), in Africa, there was only 57% coverage and 70% coverage was recorded in South-East Asia. Despite the record improvements over the years, a significant figure of 18.7 million infants below the age of 1 year had not been vaccinated with DPT3 in the entire globe. Approximately 70% of this number included children living in the middle and low income courtiers of Africa and South-East Asia. The poor coverage had consequences, in that, annually there is a record of approximately 1.5 Million Children dying from preventable conditions globally. The problem of under-vaccination and poor immunization coverage continue to exist despite the strategies put in place by both the WHO and the UNICEF. This review therefore puts in place interventions that seek to find solutions to this existing problem that continue to bite especially in the middle and low income countries.

PITCOT Table for the Selection Criteria

A number of studies were considered during the review and the main focus was on the studies conducted in the middle and low income countries especially in Africa and South-East Asia. The population of focus included children below the age five years who receive the vaccines recommended by the WHO under the routine immunization programs for children. The care givers of the children and the healthcare providers who administered the vaccines were also put in consideration in the review. Some of the studies considered dealt with individual groups while combine two or more of the groups mentioned above. As sited from Machingaidze (2013), routine immunization of children was described as regular immunization schedule given to children below the age of five years either in the facilities of healthcare or other fixed and mobile sites of outreach.

The interventions employed in the review include ones that are recipient oriented. The fist intervention as cited from Willis (2013), include those that lead to the improvement in communication concerning immunization of children such as educate or inform; recall or remind; teach skills; provision of support; and enabling of communication among others. The second interventions were provider oriented and aimed at reducing missed vaccination opportunities as well as the training and re-education of the providers. The third interventions were in line with health systems such service quality improvement; programs of outreach; increased immunization budgets; and expanded services among others. The fourth intervention was multifaceted and included a combination of any of the first three interventions. The other interventions mainly targeted the improvement of immunization coverage.

Comparisons were made based on the standards of immunization practices in the setting of the study and the various interventions implemented or just same interventions but implemented at different levels and intensity. The outcomes were dived in to two; primary and secondary. The primary outcomes involved the proportion of DPT3 administered to children below one year of age and the number of children of completed the recommended vaccines by the age of two years. The secondary outcomes included the proportion of children under study who received vaccine; the figure for children below the age of 5 years who have received full immunization according too schedule; the occurrence of diseases that are preventable through vaccination; the intervention cost; the clients and caregivers attitude towards immunization; and the adverse effects resulting from immunization.

Key Criteria used for Risk of Bias assessment

All the studies that were included in the review were assessed for the risk of bias. As cited from EPOC (2015), two authors of the review applied the EPOC criteria of risk assessment for studies such as ITS, CBAs, RCTs and NRCTs in determining the risk of bias. Disagreements were resolved through consensus and discussions or through arbitration by a third party. Every criterion used was scored as a high risk, low risk or unclear risk, depending on the individual characteristics of the included studies. In a case where the EPOC scored Yes, the study was considered a low risk while in a case where one or more criteria used in the risk assessment scored a No, the study would be labeled as high risk. If the score in the criterion used was unclear, then the study would as well be labeled unclear in terms of risk of bias. There were several key criteria used such as the concealment of the allocation; outcome data completeness; outcome assessor blinding; NRCTs and RCTs contamination protection; and intervention independence from other alterations, interventions influencing collection of data, outcome data completeness and outcomes assessor blinding in the case of ITS studies.

Summary of the Main Findings

The review brought together a number of studies that were searched electronically. The search produced about 10158 records which excluded any duplicates. The abstracts and titles of the studies were screened and a total of 79 full text studies were selected. Of the 79, 14 were included in the review while 54 were excluded. From the studies used, the inclusion criteria was met by four control trials which were individually randomized as well as tem RCTs clusters. With moderate certainty of evidence, it was found that provision of information and discussion of immunization with parents as well as the members of the community at home and in village meetings possibly improved the coverage of immunization (Lewin, 2011). It was also found that the provision of information to parents on the significance of vaccinating children during health clinic visits combined with the reminder-type messages that are specially designed can as well promote the coverage of immunization.

It was also realized that immunization coverage can probably be improved through regular outreaches on immunization, home visits as well as the integration of the programs on immunization with other primary services of healthcare like the intermittent malaria preventive treatment. With low certainty evidence it was realized that monetary incentives in the household like the unconditional or conditional transfer of cash have very minimal or even no impact on the coverage of immunization. It can therefore be said that the provision of parents and other members of the community with information concerning vaccines and immunization helps in the improvement of the immunization coverage especially in the low and middle income countries. Other avenues through the immunization coverage can be improved in such countries include the provision of health education, home visits, regular outreaches about immunization which may or may not be having incentives for households as well as the integration of the programs on immunization with other primary healthcare services.

Types of Interventions Indentified

Four major interventions were identified in the review which included recipient oriented, provider oriented, health system oriented and multi-faceted interventions. The recipient oriented interventions included health education and provision of monetary incentives. Health education is provided on the significance of completing the schedule of immunization and other issues related to immunization (Owais, 2011). Cards that acted as reminders were used to remind the caregivers on their next appointment on immunization. Pictorial cards that were easy to understand employed the use of simple language in explaining the impacts of vaccines on the lives of children as well as the location of the centers of vaccination. Monetary incentives as cited from Barham (2005) included a combination of conditional transfers of cash plus provision of free services on health and education. The condition that was attached to the cash transfer involved the reception of regular immunization, monitoring of growth, mothers attending programs on hygiene, nutrition education and health, and provision of nutritional supplements to children aged two years and below as well as lactating and pregnant mothers.

The interventions that were provider oriented entailed the training of immunization managers at the district level. The managers are trained on the audit and supervisory roles with regard to problem solving on immunization related issues. The healthcare providers were also trained on the valid and recommended vaccine doses. The intervention that were oriented to the health system involved the identification of immunized children through home visits; regular outreach sessions of immunization to ensure constant service availability; and the integration of immunization serves with other child health interventions like intermittent malaria prevention and treatment. The review considered the work of Gleton (2011) who argued that during home visits, non-immunized children are identified and they are referred to the nearest health facility for immunization. Lastly, the multi-faceted intervention involved a combination of the recipient oriented, provider oriented and the health system oriented interventions. In some cases, all the three interventions are put together while in other cases, only two are combined at a time. In such interventions, an a approach of reaching every district is put in place and a combination of several activities such as outreaches, planning, mobilization of the community, monitoring and supportive supervision is done.

Implications for future Research

The review put in place a good number of resources to support the improvement of vaccine coverage in the middle and low income counties; however, in these studies, the evidence available was only low to moderate in terms of certainty. These are the only available evidence used in the process of making informed decisions and policies in the settings under focus. As cited form Saeterdal (2014), due the low certainty, the implication is that the actual impact of the inventions will vary substantially. It is therefore recommended form the f...