Routine Vaccination Research Articles

Impact of the COVID-19 pandemic on self-paid vaccination intentions for children: a cross-sectional study in China

ObjectivesWhile it is widely accepted that COVID-19 has disrupted routine vaccination globally, the long-term impact of COVID-19 on parental vaccination intentions is uncertain. This study aims to estimate whether COVID-19...

Health and Economic Benefits of Routine Childhood Immunizations in the Era of the Vaccines for Children Program - United States, 1994-2023.

Since 1994, the U.S. Vaccines for Children (VFC) program has covered the cost of vaccines for children whose families might not otherwise be able to afford vaccines. This report assessed and quantified the health benefits and economic impact of routine U.S. childhood immunizations among both VFC-eligible and non-VFC-eligible children born during 1994-2023. Diphtheria and tetanus toxoids and acellular pertussis vaccine; Haemophilus influenzae type b conjugate vaccine; oral and inactivated poliovirus vaccines; measles, mumps, and rubella vaccine; hepatitis B vaccine; varicella vaccine; pneumococcal conjugate vaccine; hepatitis A vaccine; and rotavirus vaccine were included. Averted illnesses and deaths and associated costs over the lifetimes of 30 annual cohorts of children born during 1994-2023 were estimated using established economic models. Net savings were calculated from the payer and societal perspectives. Among approximately 117 million children born during 1994-2023, routine childhood vaccinations will have prevented approximately 508 million lifetime cases of illness, 32 million hospitalizations, and 1,129,000 deaths, at a net savings of $540 billion in direct costs and $2.7 trillion in societal costs. From both payer and societal perspectives, routine childhood vaccinations among children born during 1994-2023 resulted in substantial cost savings. Childhood immunizations continue to provide substantial health and economic benefits, while promoting health equity.

Measles: What goes around, comes around.

Measles cases are increasing globally and in the United States because of low routine measles vaccine coverage and disruptions to immunization services during the coronavirus disease 2019 (COVID-19) pandemic. To achieve and sustain measles elimination requires maintaining high coverage with 2 doses of measles vaccine, addressing vaccine hesitancy and misinformation, strong political commitment, and the necessary financial resources.

HPV vaccine behaviors and intentions among a diverse sample of women aged 27-45 years: implications for shared clinical decision-making

BackgroundThe Advisory Committee on Immunization Practices issued a shared clinical decision-making (SCDM) recommendation for HPV vaccination in persons aged 27–45. Since expanded eligibility for the vaccine was issued, little information has been available about HPV vaccine behaviors and intentions among women in this age group.MethodsWe conducted a cross-sectional online survey among women aged 27–45 years recruited through a Qualtrics™ respondent panel (N = 324) to answer the following questions (1) What is the prevalence of HPV vaccination among a diverse sample of adult women aged 27–45 years? (2) What are the characteristics of those who have or have not previously been vaccinated? and (3) What factors are associated with the intention to obtain the HPV vaccine among those who had never been vaccinated? Multivariable logistic regression analyses estimated adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs).ResultsOnly 31.1% had at least one dose of the HPV vaccine. In multivariable analyses, those more likely to have been vaccinated were younger and were more likely to believe that the vaccine was effective. Of those unvaccinated or unsure, 54.8% indicated they were likely to get vaccinated in the future. Factors associated with future vaccine intention (compared to those not intending) included beliefs about vaccine testing, perceived likelihood of HPV infection, greater comfort in asking one’s provider for vaccination, and prior negative healthcare experiences.ConclusionsOur findings suggest that many women in this age group are interested in HPV vaccination. While the recommendation is for SCDM rather than routine vaccination for all women in this age group, efforts to promote informed decision-making among mid-adult women may include educating women about the rigorous vaccine testing and approval process, their risk factors for HPV infection, and encouraging them to engage in SCDM with their medical providers. Targeted efforts to reach women who have had negative experiences with healthcare may also be needed.

Vaccine Hesitancy in the Autism Spectrum Disorder Context: Parental Vaccine Decision-Making and Coping with Stress Strategies.

Despite no scientific evidence linking vaccines to Autism Spectrum Disorder (ASD), vaccine hesitancy persists among parents of children with ASD. This study aims to compare vaccine hesitancy and behaviors among parents of children with ASD, other Neurodevelopmental Disorders (NDD), and without NDD, and to examine the relationship between stress coping mechanisms and vaccine hesitancy, including comparing coping mechanisms between diagnostic groups as well as their association with hesitancy. In this cross-sectional study, one parent of each child with ASD, non-ASD NDD, or without NDD was included. Data were collected using a researcher-created form, the Vaccine Hesitancy Scale in Turkish, and the Coping Style Scale Brief Form. Vaccine hesitancy, parents' COVID-19 vaccination status, and vaccination status of children's younger siblings were analyzed through univariate and multivariate analyses, with a focus on correlations between vaccine hesitancy and coping styles. The study included one parent from each of 299 children. Parents of children with ASD showed an adjusted odds ratio of 2.66 (95% CI 1.35-5.06) for high vaccine hesitancy, 2.57 (95% CI 1.17-5.65) for not receiving the COVID-19 vaccine, and 1.40 (95% CI 0.45-4.40) for younger siblings not receiving routine vaccines. A weak but significant correlation was observed between vaccine hesitancy and the use of restraint coping style among these parents (r = 0.280; p = 0.010). The study underscores the importance of targeted educational efforts and personalized communication to address vaccine hesitancy among parents of children with ASD. Enhancing vaccination coverage in this community requires further research to develop interventions tailored to their specific needs.

Television Viewing Frequency and Mode of Delivery Preferences among Primiparous Women in Nairobi, Kenya

Purpose: This study aims to establish television viewing frequency and mode of delivery preferences among primiparous women in Nairobi Kenya, aiming at developing informed strategies to minimize health risks and costs, promoting safer childbirth choices in a media-driven urban environment. Methodology: The study utilized a sequential mixed-methods approach, which involved 300 purposefully selected primiparous women from eleven sub-counties in Nairobi during routine child immunization schedules. Among the participants, 150 had vaginal deliveries, while the remaining underwent elective caesarean deliveries. Data collection was carried out through interviewer-administered questionnaires, focus group discussions, and in-depth interviews. Quantitative analysis involved the use of mean-weight scores, Chi-square tests, and Cramer's V using SPSS version 28.0.1.1(15). Thematic analysis was employed for qualitative data using Nvivo 14 to comprehensively understand the research topic. The findings were presented through both numerical analysis and narrative exploration. Findings: Respondents who underwent elective caesarean deliveries had higher mean TV viewing frequencies on both weekdays and weekends, compared to those who had vaginal deliveries. Both for weekdays and weekends had significant associations with moderate effect sizes. The null hypothesis was rejected due to the significant correlation and linear regression explaining 81.3% of the variability. Each additional weekday TV-watching hour increased the odds in preferring a particular mode of delivery by 40%, and on weekends, by 39%. Qualitative analysis confirmed that viewing frequency is influenced by factors such flexible schedules, cost-effectiveness, accessibility, and content preferences. Unique Contribution to Theory, Practice and Policy: The study uses cultivation and medicalization theory to establish that television viewing frequency shapes perceptions and subsequent childbirth preferences among urban women, adding to existing body of knowledge on media effects theories. To promote informed childbirth choices, recommendations include encouraging women to critically evaluate media information and seek reliable sources. Additionally, integrating media literacy into antenatal care, implementing targeted campaigns, and researching other media forms beyond television are essential.

Overview of the Treatment Goal, the Method of Evaluating Disease Activity/Physical Function, Activities of Daily Living, and Traditional Care for Systemic or Articular Juvenile Idiopathic Arthritis in Japan.

Juvenile idiopathic arthritis (JIA) is a chronic arthritis of unknown cause that develops in patients younger than 16 years of age and persists for at least 6 weeks. It is an important cause of short- and long-term physical and mental impairments in children. The goal of treatment for JIA is remission. A T2T (treatment-to-target) has been proposed and practiced as a means of achieving remission. The method of evaluating the disease activity of JIA depends on the disease type. For systemic JIA, disease activity is determined by comprehensively considering joint findings, systemic inflammatory findings, changes in inflammatory and synovitis markers, imaging findings, and other factors. For articular JIA other than systemic JIA, the Juvenile Arthritis Disease Activity Score (JADAS-27) is used to evaluate disease activity. The CHAQ (Childhood Health Assessment Questionnaire) and the Japanese version of the modified Rankin Scale (mRS) are mainly used to assess the physical function and ADL. The CHAQ is a global standard assessment method with the advantage that it can be transitioned to the HAQ used in adults, making it useful for international comparisons. The mRS is used to classify the severity of JIA as a chronic disease, and is an indispensable evaluation method in the specific disease procedure in Japan. It is necessary to have pediatric-specific knowledge of growth and development and routine childhood immunizations and to consider transition support tailored to the patient's situation. Ultimately, the goal is to foster the patient's independence and to provide an uninterrupted follow-up in the adult care department. Continuous follow-up will be provided during the schooling (and later, employment) period, and the relationship with the patient will be tailored to their developmental stage. It is also important to understand and communicate the importance of contraception and the drugs that cannot be used during pregnancy.

Esoteric beliefs and CAM impact SARS-CoV-2 immunization drivers, uptake and pediatric immunization views in Germany

Recent studies demonstrate that sociopolitical attitudes partially explain variance in (SARS-CoV-2) vaccine hesitancy and uptake. Other attitudes, such as those towards esoteric beliefs, complementary and alternative medicine (CAM), and religion, have also been proposed. However, pertinent studies provide limited direction for public health efforts, as the impact of such attitudes has been tested in isolation or on different outcomes. Moreover, related associations between SARS-CoV-2 immunization drivers as well as views towards other modes of immunization (e.g., routine pediatric immunization), remain unclear. Based on a sample of ~7400 survey participants (Germany), where esoteric belief systems and CAM (Waldorf, homeopathy) are rather prevalent, and controlling for other sociological factors, we found that (i) individuals with positive attitudes towards Waldorf education and homeopathy are significantly less likely to have received a (further) dose of SARS-CoV-2 vaccine compared to those with positive views of mainstream medicine; (ii) for the former, immunization decisions are primarily driven by external pressures, and for the latter overwhelmingly by voluntary considerations; (iii) attitudes influencing adult SARS-CoV-2 vaccine uptake similarly influence views towards routine pediatric immunization. Our findings provide significant evidence informing a more nuanced design of public health and communication campaigns, and pertinent policies.

Cost-Effectiveness of Varicella Vaccination for 1–4-Year-Olds in Shanghai, China

IntroductionVaricella has not yet been included in the National Immunization Program (NIP) in China, and varicella vaccination strategies vary by region. To determine the optimal varicella vaccination strategy in Shanghai, China, the cost-effectiveness and five-year costs of five immunization scenarios were analyzed. MethodsA static decision tree-Markov model was developed in 2022 to assess the cost-effectiveness and five-year costs of voluntary and routine varicella vaccination programs in the 2019 birth cohort in Shanghai from a societal perspective. Parameters were collected in 2022 from the varicella surveillance system, a questionnaire survey of 414 guardians of patients with childhood varicella, and semi-structured interviews with 20 experts on varicella outbreaks from different institutions in Shanghai. The outcomes included varicella cases avoided, quality-adjusted life year (QALY) loss, and incremental costs per QALY (ICER). The five-year costs were compared with local medical expenditures. ResultsAmong the five scenarios, one dose of routine varicella vaccination was the most cost-saving (USD 70.2) and cost-effective (Dominant) with a five-year immunization expenditure of USD 9.9 million. Two doses of routine varicella vaccination had the highest QALY (29.9), and its ICER (USD 791.9/QALY) was below the willingness-to-pay threshold (USD 5,203-23,767/QALY). The five-year immunization expenditure was USD 19.8 million. The effectiveness and price of vaccines, vaccination coverage, and per capita income are the four main factors that affect ICERs. ConclusionsIn Shanghai, the two doses of routine varicella vaccination strategy for 1- and 4-year-olds with a 95% coverage rate was found to be the optimal varicella immunization strategy.

Revealing the challenges and efforts of routine immunization coverage in Nigeria.

Nigeria adopted the expanded program on immunization (EPI) in 1978, which aimed at offering children under 2 years old routine immunization (RI). Early accomplishments with the program resulted in a decrease in childhood mortality. As of 2018, Nigeria accounted for about 4.3 million out of over 13 million unvaccinated children globally. Therefore, this study revealed the challenges and efforts associated with RI program in Nigeria and the way forward. In this perspective article, I conducted searches and extracted relevant information from publicly available sources such as Google Scholar, Pubmed, and grey literature. I employed RI, challenges, efforts, and Nigeria as the keywords. The 2021 Multiple Indicator Cluster Survey/National Immunization Coverage Survey reports revealed weaknesses in the program, with a national average coverage of 36%. The primary barrier to EPI across various zones is the challenge of reaching marginalized areas that were cut off from vaccination services due to operational and sociocultural issues. Some of the obstacles, such as restricted access to medical facilities, weak cold chain systems, and COVID-19 containment strategies had a great impact on the RI program. To scale up the RI program, the Nigerian government, through the National Primary Health Care Development Agency (NPHCDA), collaborated with the World Health Organization (WHO) and Gavi, the Vaccine Alliance, to optimize the "Big Catch-up campaign" and increase immunization coverage nationwide. By 2028, 80% of the projected zero-dose populace is expected to be covered, reaching these eligible children with life-saving vaccines. Nigeria still has a long way to go in making significant progress in the RI program. To further strengthen the immunization coverage, the country needs to maintain data on their achievements, as this will help identify gaps that need to be addressed in the immunization program.

Erratum to: Impact of COVID-19 Pandemic on Routine Immunization Among Tribal Children in Odisha: A Rapid Epidemiological Survey

Erratum to: Impact of COVID-19 Pandemic on Routine Immunization Among Tribal Children in Odisha: A Rapid Epidemiological Survey

Vaccines: An Emerging Multi-Modal Tool in the Fight Against Cancer.

Vaccines play an import role in cancer prevention as well as a growing role in cancer therapeutics. This article explores current knowledge regarding the role of vaccines (HPV and HBV vaccines) in protecting against preventable risk factors for select cancers as well as anti-cancer vaccines currently being used in practice. Current data suggests that routine childhood vaccination against HPV and HBV is an effective strategy for not only protecting against life-altering infectious diseases but also protecting against adult-onset cancers. Furthermore, while current vaccination practices and anti-cancer therapeutics have come a long way in recent decades, examination of CDC data also identifies areas for growth and improvement.

COVID-19 related disruption and resilience in immunisation activities in LMICs: a rapid review

ObjectivesWe conducted a rapid review to determine the extent that immunisation services in low-income and middle-income countries (LMICs) were disrupted by the COVID-19 pandemic and synthesised the factors that can...

Persepsi Orang Tua dan Pengasuh terhadap Pemberian Imunisasi Rutin pada Balita Pasca Pandemi Covid-19

Immunization is an effective strategy of the government to reduce morbidity and mortality from Preventable Diseases by Immunization (PD3I). During the Covid-19 pandemic, this situation had a significant impact on the health sector, reducing immunization coverage rates. Currently, Indonesia is in the post-Covid-19 pandemic phase characterized by positive trends in pandemic control. This study aims to understand the perceptions of parents or caregivers regarding the provision of routine immunization to children in the post-Covid-19 pandemic era. The research method used a cross-sectional design with sampling using the quota sampling method, with a total of 100 respondents. Data were collected through a questionnaire adopting the health belief model theory to parents or caregivers who brought their children to the Posyandu for immunization. The results showed that perceptions of vulnerability (p value = 0,071), seriousness (p value = 0,121), and cues to action (p value = 0,731) had an insignificant effect on immunization for toddlers, while perceptions of benefits (p value = 0,008), barriers (p value = 0,000), and self-efficacy (p value = 0,000) had a significant effect on immunization for toddlers in the post-Covid-19 pandemic era (p value < 0.05). The components of the health belief model that form the perceptions of parents or caregivers towards immunization are interconnected, although not all are statistically significant. Therefore, perceptions of vulnerability, seriousness, and cues to action need to be improved to form a good perception of immunization after the Covid-19 pandemic

Integrating Science Media Literacy, Motivational Interviewing, and Neuromarketing Science to Increase Vaccine Education Confidence among U.S. Extension Professionals.

This article presents an Integrative Model of Sustainable Health Decision-Making and a toolkit to equip U.S. Extension professionals with knowledge and skills to engage in adult immunization education. The objective was to reduce mistrust and increase willingness and confidence toward delivering vaccination education. The model was developed through an explanatory parallel mixed methods design. Data collection included a needs assessment survey, interviews, workshops, and Neuromarketing message testing. The resulting toolkit was pilot tested before final delivery. Four key needs were identified: tailoring trainings based on Extension roles, prioritizing preserving community trust and professional credibility, establishing connections with medical experts, and strengthening Science Media Literacy skills to counter misinformation and communicate emerging science. Correlations among constructs supported an integrated model focused on a professional development core of Science Media Literacy, Motivational Interviewing, and Neuromarketing Science that strengthens communication relationships between priority populations and trusted partners. The model and work described in this article can serve as a general framework for engaging key influencers in communities in communication education intended to promote sustainable well-being, such as increasing vaccine uptake.

Socio-demographic factors affecting the first and second dose of measles vaccination status among under-five children: Perspectives from South Asian countries

BackgroundThe measles vaccine is crucial in preventing fatalities and reducing widespread childhood infections worldwide, yet achieving the desired immunization rates remains a challenge in developing countries. Our study aims to identify the impact of socio-demographic factors on measles vaccination among children in South Asian countries. MethodsParticipants (89513) were taken from the most recent Demographic and Health Survey (DHS) datasets of South Asian countries between 2015 and 2021. Descriptive statistics and multivariable analyses were employed to find out the factors associated with measles vaccination among South Asian countries. ResultsOur study found that the first dose of vaccinated children was 51.7 % in Afghanistan which is the lowest among South Asian countries. The key determinants related to two doses of measles vaccination include parental characteristics, media access, and antenatal care (ANC). Mothers who had done baby postnatal checkups (AOR = 1.22, CI = 1.17–1.26) and made more than four ANC (AOR = 1.77, CI: 1.65–1.89) were more likely to fully immunize their child than mothers with no postnatal and antenatal checkups. ConclusionThe complete dose of measles vaccination rate in South Asia is still low compared to the first dose of measles vaccination among children. The government and stakeholders should organize frequent awareness programs through media and health personnel to inform people about routine vaccinations to eliminate measles.

Assessment of Complete Immunization Coverage in Infants Aged 0-12 Months

Achievement of Complete Basic Immunization (IDL) in eleven Indonesian provinces in 2022 is still below the national target of 90%. The eleven provinces in question are West Sulawesi, Southeast Sulawesi, Maluku, East Nusa Tenggara, North Kalimantan, Riau, West Kalimantan, West Papua, West Sumatra, Papua and Aceh.The type of research used in this research is descriptive observational research. The data used in this study is secondary data, namely monthly reports on the results of routine immunizations for babies. It was found that the majority of basic immunization coverage for babies born in January 2022 was higher than for babies born in January 2023. Coverage for basic immunization types for babies was highest in 2022. (73.3%) was obtained from Hepatitis B, BCG, and Polio 1 immunization. The highest coverage of basic types of infant immunization in 2023 was obtained from Hepatitis B immunization (73.3%). Hepatitis B immunization received a high score for babies born in January 2022. Coverage of basic immunization types for babies born in January 2022 for types DPT-HB-Hib 1, 2, 3, Polio 2, 3, 4, received 36.7% -73, 3%, and Measles-Rubella got 33.3%. The frequency of immunization against PVC-1 (23.3%), RV-1 (6.7%), and IPV-1 (13.3%) is still low due to not visiting posyandu and giving immunizations past the immunization deadline. The average value of basic immunization coverage for babies born in January 2023 (10%) is lower than babies born in January 2022 (43.3%) with a difference of 33.3%.

Evaluating the impact of COVID-19 on routine childhood immunizations coverage in Zambia.

There are growing concerns about the comeback of vaccine-preventable diseases. Epidemics exert shocks which affect other health performance indicators such as routine immunizations. Early model forecasts indicate decreased use of immunization services, which puts children at greater risk. Concerns about an increase in morbidity and mortality for illnesses other than COVID-19, particularly in children missing routine vaccinations, are of public health interest. In this study, we evaluate COVID-19 effects on the uptake of routine immunization in Zambia.This was an interrupted time series study. National data on routine immunization coverage between January 2017 and December 2022 were analyzed. Interrupted time series analysis was performed to quantify changes in immunization utilization. To determine if changes in the underlying patterns of utilization of immunization service were correlated with the commencement of COVID-19, seasonally adjusted segmented Poisson regression model was utilised.Utilization of health services was similar with historical levels prior to the first case of COVID-19. There was a significant drop in immunization coverage for measles dose two (RR, 0.59; 95% CI: 0.43-0.80). A decreased slope was observed in immunization coverage of Rotavirus dose one (RR, 0.97; 95% CI: 0.96-0.98) and Rotavirus dose two (RR, 0.97; 95% CI: 0.96-0.98). A growing slope was observed for Oral Poliovirus two (RR, 1.007; 95% CI: 1.004-1.011) and Oral Poliovirus three (RR, 1.007; 95% CI: 1.002-1011). We also observed a growing slope in BCG Bacille Calmette-Guerin (BCG) (RR, 1.001; 95% CI: 1.000-1011) and Pentavalent one (RR, 1.00; 95% CI: 1.001-1008) and three (RR, 1.004; 95% CI: 1.001-1008).The COVID-19 pandemic has had a number of unintended consequences that have affected the use of immunization services. Ensuring continuity in the provision of health services, especially childhood immunization, during pandemics or epidemics is crucial. Therefore, Investing in robust healthcare infrastructure to withstand surges, training and retaining a skilled workforce capable of handling emergencies and routine services simultaneously is very cardinal to avoid vaccine-preventable diseases, causing long-term health effects especially child mortality.

IMMINENT CONTESTS AND SCENARIOS OF ROTAVIRUS VACCINATION IN PAKISTAN

Background: Rotavirus is one of the significant causes of gastroenteritis in children under the age of five years. Thousands of fatalities have occurred in low socioeconomic, underdeveloped countries. It is also an essential contributor to child death in Pakistan and a critical economic burden due to hospitalization. Objectives: The Extended Program on Immunization (EPI) in Pakistan planned to include a vaccine for rotavirus in a routine immunization program for children in two doses from October 2016. Methodology: The literature was searched using databases, including Google Scholar, Scopus, and PubMed. Results: Reports on vaccination coverage have revealed a number of problems associated with inadequate vaccination coverage, such as medical malpractice, neglect, illiteracy, community issues, and denials from parents on account of their child's illness, among other things. It is also impossible to keep the appropriate vaccination program going due to a lack of personnel needed for the precise delivery of the rotavirus vaccine. Conclusion: Including this vaccine will save the lives of approximately 29,000 children every year. However, the proper administration of the rotavirus vaccine to all children who are eligible for vaccination will be a real challenge to the government and health agencies in Pakistan.

The Correlation between the knowledge and attitudes of mothers of toddlers about immunization with compliance to complete routine immunization in Wage Village, Taman Subdistrict, Sidoarjo Regency, East Java, Indonesia

Introduction: The under-five mortality rate in Indonesia and East Java in 2021 shows a downward trend from 2020, with the main cause of under-five mortality being infectious diseases such as pneumonia and diarrhea. One of the factors that contributed to this was the increase in complete immunization coverage for babies in previous years; however, in the 2021 and 2022 periods in Indonesia and East Java, there was a significant decline in the number of complete immunization coverage. Community behaviour regarding improving health, in this case, immunization, is determined by many factors, one of which is the knowledge and attitudes of the mothers of toddlers themselves. Objective: Analyzing the correlation between the knowledge and attitudes of mothers of toddlers regarding immunization and compliance with providing complete routine immunization in Wage Village, Taman District, Sidoarjo Regency, East Java, Indonesia. Method: This research used quantitative methods with a cross-sectional approach. Data was collected through questionnaires given to 90 mothers of toddlers aged 24-59 months in Wage Village who had a Healthy Way Card (KMS) or Maternal and Child Health Book (KIA); the sample size was calculated using the Compare Two Proportions formula, sampling techniques using Purposive Consecutive Sampling, and Fisher's Exact test was used to see the correlation between the two variables. Results: The results of this study show that there is no significant correlation between the knowledge of mothers of toddlers about immunization and compliance with providing complete routine immunization (p=0.434), and there is no significant correlation between the attitude of mothers of toddlers about immunization and compliance with providing complete routine immunization (p=1.000). Conclusion: The results of this study indicate that neither the knowledge nor attitudes of mothers of toddlers regarding immunization have a significant correlation with compliance in providing complete routine immunization in Wage Village, Taman District, Sidoarjo Regency. Efforts to increase immunization compliance need to focus on other aspects, such as cross-sectoral cooperation, accessibility of health services and more comprehensive education programs for mothers of toddlers, families and the community.