Improve Childhood Immunization Research Articles

Barriers to Childhood Immunisation and Local Strategies in Four Districts in South Africa: A Qualitative Study.

Introduction: In South Africa over the past 20 years, immunisation has saved countless lives as well as prevented illnesses and disabilities. Despite this, vaccine-preventable illnesses remain a danger. The demand for and uptake of immunisation services are shaped by a variety of factors that can either act as barriers or facilitators to immunisation uptake. The aim of this project was to identify the supply and demand barriers and develop local strategies to improve childhood immunisation in four zero-dose districts in South Africa. Materials and Methods: This study used a mixed-method approach. In each of these four districts, 15 in-depth key informant interviews with health workers and local health managers and four focus group discussions (10 participants per focus group discussion) with community members and caregivers were held over a three-month period. Transcribed interviews were thematically analysed using qualitative analysis software (Nvivo®) into 10 factors as identified as important in influencing immunisation demand and uptake in previous studies. A further four were identified during the data analysis process. Results: Despite the varying role of factors affecting demand and uptake of immunisation services, three consistent findings stand out as major barriers across all districts. The first is interaction with healthcare staff. This clearly highlights the crucial role that the interactions between patients and staff play in shaping perceptions and behaviours related to immunisation services. The second is the overall experience of care at healthcare facilities. This emphasises the role that patient experience of services plays in perceptions and behaviours related to immunisation services. The third is family dynamics. This highlights the important role family dynamics play in shaping individuals' decisions regarding immunisation uptake as well as the impact it has on the ability of people to access health services. Discussion: The role played by the different factors in the demand and uptake of immunisation services varied across the four districts examined in this study. Each of the districts presents a unique landscape where different factors have varying degrees of importance in affecting the utilisation of immunisation services. In some districts, certain factors are major barriers, clearly hindering the demand and uptake of immunisation services, while in others, these same factors might be a relatively minor barrier. This discrepancy highlights the unique nature of healthcare challenges across the districts and the need for tailored strategy recommendations to address them effectively.

Exploring Vaccine Hesitancy Among Parents in a Rural Pediatric Clinic System: A Statistical Study.

Vaccine hesitancy has been a growing concern in the United States, particularly in rural areas where access to healthcare services may be limited. A rural pediatric clinic system in central Louisiana serves a population with historically low childhood immunization rates. This study explored the prevalence and determinants of vaccine hesitancy among parents of pediatric patients at the organization's clinics. A qualitative survey was conducted among parents who declined vaccines for their children at the organization's clinics. The survey collected information on parents' attitudes, beliefs, decision-making processes regarding childhood vaccinations, and demographic information about the parents, including income and education levels. Thematic analysis was used to identify key themes and patterns in the survey responses. Thirty out of 47 parents (response rate: 64%) completed the survey. Most respondents (n=24, 80%) expressed concerns about vaccine safety and potential side effects. Many parents (n=16, 60%) cited information from social media and alternative health sources as influencing their decision to decline vaccines. Religious and philosophical beliefs were also common reasons for vaccine refusal (n=13, 43%). Another significant theme was the lack of trust in healthcare providers and the pharmaceutical industry (n=17, 53%). No significant differences in responses were observed based on the parent's race or the child's sex. Ninety percent of participants (n=27) reported a household income of under $50,000, and 87% of participants (n=26) had a high school education or less. Vaccine hesitancy among parents in this rural pediatric population appears to be driven by concerns about vaccine safety, exposure to misinformation, religious and philosophical beliefs, and distrust in the healthcare system. Addressing these factors through targeted education, provider communication, and community engagement may be essential for improving childhood immunization rates in this vulnerable population. The findings highlight the need for culturally sensitive, evidence-based interventions to combat vaccine hesitancy in rural communities.

Worth a Shot: Experience and Lessons From an Unsuccessful Pediatric Immunization Quality Improvement Effort in a Large Health System During the COVID-19 Pandemic.

During the coronavirus disease of 2019 (COVID-19) pandemic, routine childhood immunization rates dropped dramatically across the world, and the Military Health System (MHS) was no exception. In the MHS, which is a large, universally covered, low-to-no-cost health system, the immunization rates with the measles, mumps, and rubella (MMR) vaccine remain below the rate necessary to prevent community transmission of measles. We aimed to improve childhood immunization rates in the MHS with an expansive quality improvement project. Measles, mumps, and rubella immunization rates served as proxy outcome measures for routine immunization rates tracked by the Center for Disease Control multi-immunization combination measures. The tracked measure was the percentage of 16- to 18-month olds and 6-year olds who had received MMR #1 and MMR #2, respectively. Various countermeasures were implemented throughout the study period, and standard quality improvement analyses informed the effect of countermeasures. By January 2023, the percentage of 16- to 18-month olds and 6-year olds who had received MMR #1 and MMR #2 was 85% and 91%, respectively, with no positive shift in immunization rates despite various countermeasures introduced during the study period. For reference, the MMR immunization rates of commercial health maintenance organization and commercial preferred provider organization for 24-month-old populations were 92% and 90.3%, respectively. On chart review, the most common cause for under-immunization (55%) was vaccine abandonment. MMR #1 rates rose to 92% in 24-month olds. Measles, mumps, and rubella immunization rates within the MHS remained below commercial health system rates and below public health standards required for herd immunity despite various countermeasures throughout the COVID-19 pandemic. Immunization rates increased with age, suggesting that children within the MHS eventually catch up despite potential barriers.

Mothers/caregivers' knowledge of routine childhood immunization and vaccination status in children aged, 12-23 months in Ilorin, Nigeria.

Immunization has averted millions of hospitalizations and deaths from vaccine-preventable diseases. It is a strong public health tool for childhood infection control and prevention. Many mothers are aware of routine immunization but with doubtable knowledge. This study determined the mothers/caregivers' knowledge of routine childhood immunization and vaccination status of their children, aged 12-23 months in Ilorin East Area of Kwara State, Nigeria. It also identified some of the socio-demographic factors associated with good knowledge status of the mothers/caregivers. This was a community-based cross-sectional study, carried out between December, 2019 and January, 2020, among 456 mothers / caregivers-children's pairs. Subjects were recruited using multistage cluster sampling technique. Data were collected using a pretested, semi-structured, interviewer-administered questionnaire. Up to 98.0% of the respondents were aware of childhood immunization with healthcare providers (92.1%) being their major source of information. Majority of the respondents (85.3%) had good knowledge of immunization, defined by a score ≤6 out of the 10 questions tested. There was a significant relationship between respondents' knowledge and full vaccination status of the children (p=0.001). The significant factors associated with good knowledge from binary logistic regression were mothers / caregivers' age >30 years, antenatal clinic attendance and at least secondary education (OR, p value = 10.60, 0.013; 8.50, <0.001; and 3.98, <0.001 respectively). Mothers / caregivers' knowledge on immunization was good and this positively affected the full vaccination status of their children. There is a need to sustain female education and encourage antenatal clinic attendance, as tools to improve childhood immunization.

Improved vaccine coverage for First Nations children receiving first dose on-reserve: a retrospective cohort study in western Canada

IntroductionFragmentation in immunisation reporting systems pose challenges in measuring vaccine coverage for First Nations children in Canada. Some Nations have entered into data-sharing agreements with the province of Alberta’s health...

Evaluation of the impact of an intervention programme to revamp cold chain system and improve childhood immunization in Egbedore, Nigeria: a retrospective study

Background: In 2016, the immunization coverage in Nigeria ranged from 3% in Sokoto State to 80% in Lagos State while the national coverage was 33.3%. This is lower than the world health organization’s recommendation of over 90%. Immunization coverages in Osun State and Egbedore, Osun State (the study area) were 60% and 83% in respectively. Immunizations for specific vaccine preventable diseases are given to reduce infant morbidity and mortality. An intervention programme to revamp cold chain system was conducted to increase the immunization coverage and reduce the proportion of unimmunized children in Egbedore. The intervention programme comprised of focus group discussion involving immunization teams and mothers of under-five children, cold-chain inventory, observation of normal routine immunization (RI) sessions and observation of immunization outreaches. The aim of this study is to evaluate the impact of the intervention programme toward improving childhood immunization and increasing child survival in Egbedore Methods: The study utilized a retrospective design, purposive sampling technique and secondary data. Results: The result showed that before the intervention the proportion of unimmunized children for oral polio vaccine-3 (OPV3) was 0.27 which reduced to 0.17 (χ2=169.441, p&lt;0.0001) after the intervention while for pentavalent vaccine-3, the proportion of children unimmunized was 0.28 before the intervention and reduced to 0.19 after the intervention, (χ2=171,059, p&lt;0.0001) Conclusions: The study concluded that regular cold chain equipment (CCE) inventory, repair and supply are germane to ensuring functionality while at least five immunization outreaches are required to be conducted per political ward to enhance optimal immunization coverage.

Childhood Immunization and Competing Mortality Risks in Kenya: A Longitudinal Analysis for Multiparous Mothers

To assess the relationship between childhood immunization and mortality risks for nonvaccine-preventable diseases (competing mortality risks, or CMR) in Kenya. A combination of the Global Burden of Disease and Demographic Health Survey data was used to measure basic vaccination status, CMR, and control variables for each child in the Demographic Health Survey data. A longitudinal analysis was performed. This uses within-mother variation between children to compare the vaccine decisions for different children, who are exposed to different mortality risks. The analysis also distinguishes between overall and disease-specific risks. The study included 15 881 children born between 2009 and 2013, who were at least 12months old at the time of interview and not part of a twin birth. Mean basic vaccination rates ranged from 27.1% to 90.2% and mean CMR from 13.00 to 738.32 deaths per 100 000 across different counties. A one-unit increase in mortality risk from diarrhea, the most prevalent disease among children in Kenya, is associated with a 1.1 percentage point decline in basic vaccination status. In contrast, mortality risks for other diseases and HIV increase the likelihood of vaccination. The effect of CMR was found to be stronger for children with higher birth orders. A significant negative correlation between severe CMR and vaccination status was found, which has important implications for immunization policies, particularly in Kenya. Interventions aimed at reducing the most severe CMR, such as diarrhea, and targeted toward multiparous mothers may improve childhood immunization coverage.

Mobile Applications in Childhood Immunization: A Systematic Review

The central objective of this paper is to distinguish the impact of different cell phone applications on child vaccination completion. A systematic literature review was conducted to determine how mobile applications have improved the acceptance, education, and fulfillment of vaccines. To this end, an analysis of the aspects, objectives, and differentiated technologies that have fostered the growth of mobile applications and new technologies in childhood immunization is presented. In addition, the obstacles to achieving positive results reported in the scientific literature are identified. Lastly, suggestions are made for future work to improve childhood immunization coverage.

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children.

Understanding past successes in reaching unvaccinated or "zero-dose" children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Focusing on 2000-2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria-tetanus-pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential 'exemplars', demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called "neighborhood analyses" were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions-national prevalence and subnational gaps-while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children-especially across variable contexts and different drivers of inequality-could support faster, sustainable advances toward greater vaccination equity worldwide.

The AuTOMATIC trial: a study protocol for a multi-arm Bayesian adaptive randomised controlled trial of text messaging to improve childhood immunisation coverage

BackgroundWhile most Australian children are vaccinated, delays in vaccination can put them at risk from preventable infections. Widespread mobile phone ownership in Australia could allow automated short message service (SMS) reminders to be used as a low-cost strategy to effectively ‘nudge’ parents towards vaccinating their children on time.MethodsAuTOMATIC is an adaptive randomised trial which aims to both evaluate and optimise the use of SMS reminders for improving the timely vaccination of children at primary care clinics across Australia. The trial will utilise high levels of digital automation to effect, including eligibility assessment, randomisation, delivery of intervention, data extraction and analysis, thereby allowing healthcare-embedded trial delivery. Up to 10,000 parents attending participating primary care clinics will be randomised to one of 12 different active SMS vaccine reminder content and timing arms or usual practice only (no SMS reminder). The primary outcome is vaccine receipt within 28 days of the scheduled date for the index vaccine (the first scheduled vaccine after randomisation). Secondary analyses will assess receipt and timeliness for all vaccine occasions in all children. Regular scheduled analyses will be performed using Bayesian inference and pre-specified trial decision rules, enabling response adaptive randomisation, suspension of any poorly performing arms and early stopping if a single best message is identified.DiscussionThis study will aim to optimise SMS reminders for childhood vaccination in primary care clinics, directly comparing alternative message framing and message timing. We anticipate that the trial will be an exemplar in using Bayesian adaptive methodology to assess a readily implementable strategy in a wide population, capable of delivery due to the levels of digital automation. Methods and findings from this study will help to inform strategies for implementing reminders and embedding analytics in primary health care settings.Trial registrationANZCTR: ACTRN12618000789268.

Implementing SMS reminders for routine immunization in Northern Nigeria: a qualitative evaluation using the RE-AIM framework

BackgroundShort Message Service (SMS) reminders have improved vaccine uptake in low- and middle-income countries (LMICs). However, the limited use of SMS reminders in LMICs requires evaluating the intervention’s internal and external validity to improve adoption and sustainability. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we qualitatively assessed the impact of a SMS reminder intervention implemented in Kebbi State, Northwest Nigeria between May 20, 2019 and May 31, 2020. This will guide and inform future SMS reminder interventions to improve childhood immunization uptake in LMICs.MethodsIn June 2020, we conducted 14 focus group discussions, 13 in-depth interviews, and 20 key informant interviews among 144 purposively selected participants from five local government areas of Kebbi State. For analysis, we used a deductive approach to develop preliminary codes based on the RE-AIM framework and the inductive approach to generate themes that emerged from the interviews.ResultsThe perceived importance and impact of the SMS reminder in improving demand and uptake for vaccinations were the consistent contributing factors that encouraged participants’ participation. Other facilitators included the involvement of health workers in supporting SMS reminder registration and community gatekeepers using existing structures to convey messages on scheduled immunization services. Policymakers adopted the intervention because it aligns with the state’s priority to improve immunization coverage. Similarly, the SMS reminder appealed to health workers and program managers because it reduced their workload and served as a performance monitoring tool to track immunization and intervention defaulters. Despite these, low mobile phone ownership and the inability to read text messages due to the low literacy level were the main barriers during implementation. Finally, data availability on cost-effectiveness and the intervention’s impact on improving coverage was critical for scalability.ConclusionsOur study demonstrated that SMS reminders in local languages could improve vaccination demand and uptake in resource-constrained settings due to their perceived importance and impact. Addressing the cited implementation barriers and promoting the facilitators is critical to its adoption and sustainability. Costing and impact data are needed to collaborate findings on the effectiveness of the SMS reminder to improve childhood vaccination uptake.

Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries.

The role of gender inequality in childhood immunization is an emerging area of focus for global efforts to improve immunization coverage and equity. Recent studies have examined the relationship between gender inequality and childhood immunization at national as well as individual levels; we hypothesize that the demonstrated relationship between greater gender equality and higher immunization coverage will also be evident when examining subnational-level data. We thus conducted an ecological analysis examining the association between the Subnational Gender Development Index (SGDI) and two measures of immunization-zero-dose diphtheria-tetanus-pertussis (DTP) prevalence and 3-dose DTP coverage. Using data from 2010-2019 across 702 subnational regions within 57 countries, we assessed these relationships using fractional logistic regression models, as well as a series of analyses to account for the nested geographies of subnational regions within countries. Subnational regions were dichotomized to higher gender inequality (top quintile of SGDI) and lower gender inequality (lower four quintiles of SGDI). In adjusted models, we find that subnational regions with higher gender inequality (favoring men) are expected to have 5.8 percentage points greater zero-dose prevalence than regions with lower inequality [16.4% (95% confidence interval (CI) 14.5-18.4%) in higher-inequality regions versus 10.6% (95% CI 9.5-11.7%) in lower-inequality regions], and 8.2 percentage points lower DTP3 immunization coverage [71.0% (95% CI 68.3-73.7%) in higher-inequality regions versus 79.2% (95% CI 77.7-80.7%) in lower-inequality regions]. In models accounting for country-level clustering of gender inequality, the magnitude and strength of associations are reduced somewhat, but remain statistically significant in the hypothesized direction. In conjunction with published work demonstrating meaningful associations between greater gender equality and better childhood immunization outcomes in individual- and country-level analyses, these findings lend further strength to calls for efforts towards greater gender equality to improve childhood immunization and child health outcomes broadly.

Text Message Reminders to Improve Immunization Appointment Attendance in Alberta, Canada: The Childhood Immunization Reminder Project Pilot Study.

Vaccine coverage for 18-month-old children in Canada is often below the recommended level, which may be partially because of parental forgetfulness. SMS text message reminders have been shown to potentially improve childhood immunization uptake but have not been widely used in Alberta, Canada. In addition, it has been noted that language barriers may impede immunization service delivery but continue to remain unaddressed in many existing reminder and recall systems. This study aimed to assess the effectiveness and acceptability of using SMS text messages containing a link to web-based immunization information in different languages to remind parents of their child's 18-month immunization appointment. The Childhood Immunization Reminder Project was a pilot intervention at 2 public health centers, one each in Lethbridge and Edmonton, Alberta, Canada. Two SMS text message reminders were sent to parents: a booking reminder 3 months before their child turned 18 months old and an appointment reminder 3 days before their scheduled appointment. Booking reminders included a link to the study website hosting immunization information in 9 languages. To evaluate intervention effectiveness, we compared the absolute attendance no-show rates before the intervention and after the intervention. The acceptability of the intervention was evaluated through web-based surveys completed by parents and public health center staff. Google Analytics was used to determine how often web-based immunization information was accessed, from where, and in which languages. Following the intervention, the health center in Edmonton had a reduction of 6.4% (95% CI 3%-9.8%) in appointment no-shows, with no change at the Lethbridge Health Center (0.8%, 95% CI -1.4% to 3%). The acceptability surveys were completed by 222 parents (response rate: 23.9%) and 22 staff members. Almost all (>95%) respondents indicated that the reminders were helpful and provided useful suggestions for improvement. All surveyed parents (222/222, 100%) found it helpful to read web-based immunization information in their language of choice. Google Analytics data showed that immunization information was most often read in English (118/207, 57%), Punjabi (52/207, 25.1%), Arabic (13/207, 6.3%), Spanish (12/207, 5.8%), Italian (4/207, 1.9%), Chinese (4/207, 1.9%), French (2/207, 0.9%), Tagalog (1/207, 0.5%), and Vietnamese (1/207, 0.5%). The study's findings support the use of SMS text message reminders as a convenient and acceptable method to minimize parental forgetfulness and potentially reduce appointment no-shows. The diverse languages accessed in web-based immunization information suggest the need to provide appropriate translated immunization information. Further research is needed to evaluate the impact of SMS text message reminders on childhood immunization coverage in different settings.

Barriers, facilitators, and recommendations for childhood immunisation in Nigeria: perspectives from caregivers, community leaders, and healthcare workers.

vaccination is one of the most successful and cost-effective public health interventions, significantly reducing childhood morbidity and mortality. In 2019, Nigeria had almost 2.5 million unvaccinated children. This study highlights barriers, facilitators, and recommendations for childhood immunisation uptake from various stakeholder perspectives. the study team conducted ten focus groups with mothers/caregivers and community leaders and nine semi-structured interviews with healthcare workers who provide routine immunisation services in Lagos State primary healthcare facilities. We performed a descriptive thematic analysis of the focus groups and semi-structured interviews. study participants included 44 mothers/caregivers and 24 community leaders, and 19 primary healthcare workers in the State. Study participants reported barriers, facilitators, and recommendations for childhood immunisation uptake. Barriers include poor geographical and financial constraints to access healthcare services, inconducive health facility attributes, negative attitudes of health facility staff, vaccination misperceptions, and adverse events following immunisation. Facilitators include free immunisation service policy, optimal vaccine and device supply chain system, adequate knowledge of immunisation benefits and efficacy, vaccination outreaches, and provision of incentives to caregivers. Participants also made recommendations for implementation, including more awareness creation, use of community resources, employing more healthcare workers, frequent and optimal immunisation services and planning, and instituting a reminder system and defaulter tracking. Conclusion: our results can inform the development of interventions to improve childhood immunisation uptake. In addition, study findings can be employed to improve adult immunisation acceptance and uptake and other services provided within the primary healthcare setting.

Improved childhood immunization coverage using the World Health Organization’s Tailoring Immunization Programmes guide (TIP) in a regional centre in Australia

In 2017 the World Health Organization’s Tailoring Immunization Programmes guide (TIP) was used to identify pockets of low immunization coverage in Australia. The regional centre of Maitland had high numbers and rates of children who were overdue for scheduled vaccinations (2016, n = 344, 37.7%). Families were not opposed to immunization but had conflicting priorities or experienced service access barriers. A tailored strategy was developed including friendly, personalised reminders, outreach appointments and home visiting for those families most in need. Research translation was not quick and easy. A process evaluation identified areas where more support was needed to advance the strategy. Coverage rates have increased from 62.3% (2016) to 86.2% (2020). The number of overdue children has decreased even during COVID-19 restrictions when health services expected families would avoid primary care services. The TIP approach is valuable for improving childhood immunization coverage and is being utilised in other communities with low coverage.

A rapid qualitative assessment of barriers associated with demand and uptake of health facility-based childhood immunizations and recommendations to improve immunization service delivery in Sokoto State, Northwest Nigeria, 2017.

IntroductionThis rapid qualitative assessment aimed to understand factors associated with persistent low vaccination demand and uptake, and recommendations to improve health facility-based childhood immunization services in Sokoto State, Nigeria.MethodsIn 2017, 20 focus group discussions and 16 in-depth interviews were conducted with administrative personnel, healthcare workers, caregivers, and community influencers across three local government areas in Sokoto state, Northwest Nigeria. Participants were purposefully selected to capture a range of perspectives regarding access to health services, campaign- and facility-based immunizations, confidence in immunizations, and recommendations to improve childhood immunization uptake.ResultsOne hundred and ninety-three individuals participated in the assessment. Commonly reported barriers to receiving childhood immunizations include: inadequacy of health services to meet community needs, preference for campaign vs. facility-based immunizations, the negative influence of rumors and misinformation, and opposition to vaccines among male heads of households. Recommendations to improve uptake of childhood immunizations include: improving immunization service delivery in health facilities, involving community leaders in building demand for immunization, and providing access to free health services and non-cash incentives.ConclusionRapid assessment results highlight community, facility, and administrative barriers associated with low demand for and uptake of health facility-based childhood immunizations and offer recommendations to improve immunization services in Sokoto state, Nigeria. Findings demonstrate the persistence of service and supply side barriers such as infrastructure and personnel issues, but also highlight the influence of behavioral factors such as low prioritization of receiving childhood immunizations, misinformation, and gender dynamics on whether communities accept or seek out immunization services.

Increasing the demand for vaccination through mHealth in Quetta City, Balochistan in Pakistan

Background Balochistan is the largest province of Pakistan by area, and the least developed. It suffers from several political, tribal and border conflicts. The distances to health facilities for the catchment population are long with limited accessibility. Immunization is one of the most cost-effective interventions to prevent deaths from vaccine preventable diseases (VPDs), especially in children. While Pakistan has an overall routine immunization coverage of 66 per cent for fully immunized children (FIC), coverage in the province of Balochistan is much lower at 29 per cent. This study aimed to assess the feasibility of introducing mHealth intervention using an artificial intelligence (AI) platform based on SMS (short-message service) and Interactive Voice Response (IVRs) to remind and persuade parents to get their children vaccinated. Methods We employed a mixed study design using both quantitative and qualitative approaches. Baseline data were collected from 1,600 eligible mothers/parents within the catchment areas of 75 basic health units (BHUs) in Quetta (provincial capital of Balochistan province), and the automated platform was instituted with SMS and IVRs from EPI (Expanded Programme on Immunization) Quetta. Daily reminders and IVRs were sent to the cell numbers in the database/records. Responses were noted on the AI platform. After a period of about two months, an end line survey of 1,203 participants was undertaken with a loss of 397 (25%) participants due to seasonal migration to warmer cities in Sindh province. For the qualitative part, three key informant interviews (KII) were conducted; two KIIs with Lady Health Supervisors and one KII with the WHO staff responsible for routine immunization. There were also three focus group discussions (FGDs). Results We found that the intervention was feasible as well as acceptable both at the community and programme management levels. The baseline indicators of immunization coverage improved significantly on end line survey (95% confidence interval, CI = 0.208-0.269; P&lt;0.001). Conclusions Our study demonstrates the potential for mHealth and AI to improve childhood immunization and addresses equity in the least developed areas of this country. The replication of the strategy in subnational immunization programmes could decrease morbidity and mortality due to VPDs.

Impact of antenatal care visits on childhood immunization: a propensity score-matched analysis using nationally representative survey.

Evidence has suggested a relationship between antenatal care (ANC) visits and childhood immunization coverage. However, evaluating its impact using observational data suffers from the problem of selection bias. Hence, we adopted propensity score-matched (PSM) analysis for studying the impact of ANC visits on childhood immunization. Data regarding ANC visits and childhood immunization were collected from a nationally representative survey, National Family Health Survey-4 (NFHS-4). We performed PSM analysis with logit model using the psmatch2 command package in STATA to find the average treatment effect on the population (ATE), treated (ATT), and untreated (ATU). In total, 5,430 participants were included in the analysis. Radius matching with caliper width of 0.01 was used to match the groups. The ATT values in the intervention and control groups were 0.71 and 0.47, respectively, indicating that the immunization coverage was increased by 24% because of ANC visits. The ATU values in the intervention and control groups were 0.40 and 0.65, respectively. This indicates that for the women who did not make the ANC visits, the chance of getting their children immunized would have increased by 25% if they had made four or more visits. The final ATE estimate was 0.25 among the study participants. Quality of matching was good with no significant difference in characteristics between the two groups. Findings from our study imply that policymakers in India should focus on further improving the ANC coverage as it has a significant impact on improving childhood immunization coverage.

Missed opportunities for vaccination among children aged 0–23 months visiting health facilities in a southwest State of Nigeria, December 2019

BackgroundDespite efforts to improve childhood immunization coverage in Nigeria, coverage has remained below the national acceptable level. In December 2019, we conducted an assessment of Missed Opportunities for Vaccination (MOV) in Ondo State, in Southwest Nigeria. The objectives were to determine the magnitude of, explore the reasons for, as well as possible solutions for reducing MOV in the State.MethodsThis was a cross-sectional study using a mixed-methods approach. We purposively selected 66 health facilities in three local government authorities, with a non-probabilistic sampling of caregivers of children 0–23 months for exit interviews, and health workers for knowledge, attitudes, and practices (KAP) surveys. Data collection was complemented with focus group discussions and in-depth interviews with caregivers and health workers. The proportion of MOV among children with documented vaccination histories were determined and thematic analysis of the qualitative data was carried out.Results984 caregivers with children aged 0–23 months were interviewed, of which 869 were eligible for inclusion in our analysis. The prevalence of MOV was 32.8%. MOV occurred among 90.8% of children during non-vaccination visits, and 7.3% during vaccination visits. Vaccine doses recommended later in the immunization series were given in a less timely manner. Among 41.0% of health workers, they reported their vaccination knowledge was insufficient. Additionally, 57.5% were concerned about and feared adverse events following immunization. Caregivers were found to have a low awareness about vaccination, and issues related to the organization of the health system were found to contribute towards MOV.ConclusionsOne in three children experienced a MOV during a health service encounter. Potential interventions to reduce MOV include training of health workers about immunization policies and practices, improving caregivers’ engagement and screening of vaccination documentation by health workers during every health service encounter.

Every Child on the Map: A Theory of Change Framework for Improving Childhood Immunization Coverage and Equity Using Geospatial Data and Technologies

The effective use of geospatial data and technologies to collect, manage, analyze, model, and visualize geographic data has great potential to improve data-driven decision-making for immunization programs. This article presents a theory of change for the use of geospatial technologies for immunization programming—a framework to illustrate the ways in which geospatial data and technologies can contribute to improved immunization outcomes and have a positive impact on childhood immunization coverage rates in low- and middle-income countries. The theory of change is the result of a review of the state of the evidence and literature; consultation with implementers, donors, and immunization and geospatial technology experts; and a review of country-level implementation experiences. The framework illustrates how the effective use of geospatial data and technologies can help immunization programs realize improvements in the number of children immunized by producing reliable estimates of target populations, identifying chronically missed settlements and locations with the highest number of zero-dose and under-immunized children, and guiding immunization managers with solutions to optimize resource distribution and location of health services. Through these direct effects on service delivery, geospatial data and technologies can contribute to the strengthening of the overall health system with equity in immunization coverage. Recent implementation of integrated geospatial data and technologies for the immunization program in Myanmar demonstrate the process that countries may experience on the path to achieving lasting systematic improvements. The theory of change presented here may serve as a guide for country program managers, implementers, donors, and other stakeholders to better understand how geospatial tools can support immunization programs and facilitate integrated service planning and equitable delivery through the unifying role of geography and geospatial data.