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Master Of Public Health: Childhood Vaccination

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The rate of full immunization coverage for children has not been achieved equally in low developed countries compared to developing countries. According to the WHO report for achieving target immunization coverage for vaccine like DTP, countries like Africa and South East Asia are still short of the target of 90%. Many barriers to achieving vaccination target has been found to contribute to the trend in low developing countries. Some of these barriers include poor parent education, low income and poor access to health care facilities (World Health Organization, 2017). As a staff working in health department of Maharashtra, India, I have been given the task of evaluating the effectiveness of various interventions to determine whether investment should be done to improve vaccination rate according to new policy directive or not. Hence, this report mainly review the findings from the Cochrane review of the article on ‘Interventions for improving coverage of childhood immunization in low and middle-income countries’ and evaluates the applicability of the Cochrane review findings on improving vaccinate rates in India particularly Maharashtra. The structured assessment is likely to influence the decision regarding investing for vaccination efforts in the chosen country.


Childhood vaccination issues in India:

The Government of India focused on intensification of childhood immunization in remote and inaccessible rural areas in the year 2012-2013 and their target was also to eradicate polio transmission and measles from the country by 2010 (Bhatnagar et al., 2016). According to national immunization coverage for 2015, 87% vaccination rate was achieved for BCG, DTP3 and MCV1. The government was involved in 39% spending on vaccines and 42% spending on routine immunization programme (EPI Fact Sheet, 2017). This reflects that advances in immunization coverage rates has been achieved, however still India has fallen short of coverage for all children because of many management challenges. Some of the reasons for poor vaccine coverage back in the 1990s included extreme focus on polio eradication at the expense of other vaccines, insufficient investment of government in vaccination coverage, presence anti-vaccine advocates as well as poor education in people. The quality of supply chain and infrastructure was also found to affect the vaccination coverage because 25% of vaccines did reached health care clinics and doctors and they were wasted (Centre for Public Impact, 2017).

The evaluation of more recent statistics on coverage for DPT vaccine revealed that 19.3 million infants in 2010 remain unimmunized globally and India achieved only 61% immunization coverage in 2011. The investigation regarding the reason for such trend revealed that dropout rates was higher in migrant groups because of poor service utilization and inability to complete full course of vaccination (Progress Towards Global Immunization Goals, 2017). As 2012 became the year of intensification of routine vaccination particularly in remote and backward areas, Nath, Kaur, & Tripathi, (2015) investigated about the challenges in vaccination rate among migrant population in Uttarakhand, India. The main findings from the study was that gap in immunization coverage was seen because of inadequate cold chain maintenance, poor tracking of dropouts and poor training in staffs regarding maintaining the temperature of vaccines. In case of mothers, the main reason for non-immunization included the preference for vaccinating child in resident district only and lack of awareness about session site location. Review of these challenges in achieving vaccination rates in India mainly suggest that tailored strategies as intervention were not taken to specifically target immunization coverage in people living in rural and remote areas particularly with low education. It also points out to weakness in counseling efforts to change the attitude of parents towards the immunization process.

As this report is mainly focused on evaluating applicability of Cochrane review findings particularly for Maharashtra, analyzing the challenges in vaccination coverage in the state is also necessary. The study by Gatchell, Thind, & Hagigi, (2008) pointed that for children in Maharashtra, education in parents increased the likelihood of completing immunization in children compared to uneducated parents. Receipt of antenatal care and exposure to TV was a strong predictor of complete immunization however household standard of living also affected the immunization status of children. One unique finding for Maharashtra was that children in rural areas were more likely to be completely immunized compared to those in urban areas. This is an indication that rural infrastructure is strong in Maharashtra and more efforts is required in improving coverage in urban areas. Scheduled caste related biasness in coverage was also seen suggesting more interventions targeting this group. Hence, consideration of state level determinant of immunization is crucial to improving overall immunization rates in India.


Summary of the findings of the Cochrane review:

The Cochrane review of the article on ‘Interventions for improving coverage of childhood immunization in low and middle income countries’ revealed about types of interventions implemented in countries like Ghana, India, Nepal, Pakistan and many other low developing countries. Some of the relevant interventions implemented for improving childhood immunization coverage included providing community based health education, facility based health education and redesigned reminder cards, monetary incentives, home visits, immunization outreach with and without incentives and integration of immunization with other health services. In terms of effectiveness, moderate evidence was found for communication regarding vaccination in parents and other community members (Oyo?Ita et al., 2012). However, for other interventions like use of reminder card, regular immunization outreach home visits and integration of immunization with primary health care service, low certainty evidence was found for immunization coverage. This indicates that strong evidence was not present for the effectiveness of one type of intervention to improve the coverage.

The author also presented limitations in each intervention with proper arguments and raising arguments regarding varied intensity and content of each intervention. For example, the  community based education intervention was given with the purpose of educating people about the benefits and risk of vaccination and how and where to received vaccine services. However, the feasibility of this approach is not clear because no evidence is present for the impact of such intervention in improving completion of the immunization schedule (Oyo?Ita et al., 2012). Another intervention identified in the Cochrane review was related to community based health education and again effect of such intervention was questioned in a community with low literacy. Another study also regarding monetary incentive intervention to beneficial in imprpvong immunization rate in a family with poor economic resource, but the methodological challenge in this process is that how donor support and incentive could be arranged in specific locations (Oyo?Ita et al., 2012). This mainly indicates that studies are presented but poor presentation of effectiveness restricts the wider applicability of the study.

The study was useful in showing about the lack of evidence on the approach taken to promote the sustainability of the interventions. The author also presented the barrier to the applicability of the interventions in real setting. For instance, applicability may be affected by the level of education in immunization health workers and poor access to relevant resource and infrastructure related to immunization coverage. Hence, it can be said that resource played an critical role in the success of any intervention and to determine the long-term sustainability and cost effectiveness of any interventions, data related to resource implications must be comprehensively analysed. In addition, there is a need for well-conducted RCT studies to get high certainty evidence regarding the efficacy of intervention in improving childhood immunization coverage.

Structure discussion of five support questions:

The main purpose of evaluation of interventions mentioned in the Lavis et al., (2009) is to determine whether any of the intervention can be applied in the health care system of India and particularly the state of Maharashtra or not. The author of the Cochrane review mainly supported interventions like providing information to parents and community members about immunization, combination of health education and redesigning immunization reminder card, home visits and integration of immunization with other service to improve immunization coverage in low and middle income countries (Oyo?Ita et al., 2012). The structured assessment for applicability of the Cochrane review is mainly done by use of five questions from the Lavis et al., (2009) as the support tool particularly ensures that decisions are well-informed and critical assessment of intervention according to local context is possible.

Consistency of findings across settings or time periods

The first criterion for evaluation of the study are to find out whether the findings are based in the same setting as the policy maker or the reviewer or not. The main purpose of this study is to evaluate the applicability of the intervention for the health care system of India. However, the systematic review included fourteen studies and it include two studies from India and other studies from the country of Ghana, Mexico, Honduras, Pakistan, Zimbabwe and Nepal (Oyo?Ita et al., 2012). This means that local applicability of the intervention is doubtful for the health care system of India. However, consistency of finding across all settings can also give an idea about local applicability of the interventions. For all the studies done across different settings, low certainty evidence was present for effectiveness. Therefore, consistency across different settings was not found. In addition, major studies were published between the 2004 to 2011, however some were published in 1998 and 1996 too. It is not clear whether the finding is consistent across time periods.  Hence, the study done in Indian settings needs to be evaluated to understand whether they can be implemented in the state of Maharashtra or not.

The intervention done in Indian setting investigated about the immunization outreach with and without incentives by means of a clustered randomized controlled trial. The study was done in a rural setting of Rajasthan and three groups in the study included monthly immunization camp, immunization camps with incentive and the controls groups. The survey with participants in randomly selected households revealed that full immunization rate was higher for the immunization group with incentive compared to the control group. The average cost per immunization was higher for group with incentive compared to without intervention group. The main conclusion from the study was that small incentives can have a positive impact in improving immunization coverage in areas with poor resource (Banerjee et al., 2010). As this study has been done in rural setting, it can be said that this type of intervention can be applied in Maharashtra only in rural and remotes areas where people do not have access to reliable immunization camp. The transferability and effectiveness of this intervention is high for low income areas. This is considered a reliable intervention for rural setting because another study showed that introduction of food/medicine vouchers as incentive to mothers increases the completion of DTP coverage by two fold in low socio-economic area (Chandir et al., 2010). Hence, similar approach is likely to work in rural areas of Maharashtra or any other state in India.

In the context of Maharashtra and India, immunization with incentive intervention is not likely to be effective and reliable in urban areas. Review of studies done in other countries will also not help to determine the applicability of any intervention for India because the health care system of India will differ from that of other countries. The immunization service outreach urban children may differ based on standard of living index. The review of challenges faced in achieving immunization target in India or Maharashtra may also help in determining the most effective intervention for urban areas. The study on trends in child immunization across geographical regions in India has revealed that urban-rural different and gender equity in different states has an impact on immunization coverage. In Maharashtra, particularly, the gender equality ratio is high and gender inequality challenges in full immunization coverage needs to be considered (Singh, 2013). Hence, this element needs to be considered in intervention for improving coverage in Maharashtra.


Factors affecting the feasibility or acceptability of intervention options:

The systematic review proposed various interventions for improving the childhood immunization coverage. However, their feasibility and acceptability may be affected by ground realities and political or other constraints faced in India, hence before deciding on any intervention for Maharashtra, the links with ground realities needs to be analysed. In terms of ground realities, the main challenges is that health worker density is low in India and the distribution of health workers remains a barrier to Universal Health coverage. Association has been found between shortage of health workers and poorer health outcomes in Indian state. Hence, if any interventions focuses on community based health educations, the shortage of community health workers in any Indian state will reduce the applicability of the intervention. The rural-urban division also affects immunization coverage and for rural areas of Maharashtra, the trend is different as the immunization coverage is rural area of the state is much better than other Indian states. Another insight from evaluation of immunization coverage in Maharashtra was that only 60% has immunization card and in this aspect, the interventions related to redesigned reminder cards might work for the target setting (Gupta, Pore, & Patil, 2013). Hence, in the context of health care system of India, the facility based health education plus redesigned reminder cards may be feasible as an intervention for immunization coverage.

Another factor affecting the feasibility of any interventions in Indian setting is the issue of gender bias in the population. Mathew et al., (2017) studied about the barrier to immunization among women in an Indian state and this mainly showed that attitudinal barrier to immunization was high. For instance, poor male participation, gender bias, lack of family support, poor attitude towards vaccinisation in elderly, strange rumors and apprehension of getting many vaccines acted as the barrier in immunization coverage. Hence, an intervention may become less applicable for Indian context if it does not address attitudinal barriers in interventions. In this context, role of health personnel and effective counseling and health education sessions is likely to be feasible in improving immunisation rate in the health care system of India. This type of evaluation in terms of ground realities is necessary to confirm the applicability of any intervention in local setting because diffusion of evidence into policy depends largely on the factors involved at each stage of the adoption process (Bowen & Zwi, 2005).


Role of health system arrangements in affecting the feasibility of intervention

Oyo?Ita et al., (2012) included articles in the studies which included low developing countries like Nepal, Pakistan, Zimbabwe and others which might have different health system arrangements than India. In such case, the evaluation of the intervention needs to be done on the basis of health system arrangements that alters outcome of the intervention. For instance, the monetary incentive intervention in the form of household cash transfer done in Zimbabwe and Nicargua may give alternative results in India. In the context of health care system arrangement in India, the universal immunization program in India covers free vaccination against 12 life threatening diseases and there is an impetus to develop new vaccines and improve the quality of vaccines. Work is also going on address gaps in cold-chain management (Dang, 2017). However, no systematic arrangement has been found to permanently provided incentive related benefits to target group to achieve the full immunization goals.  Without such arrangement, any incentive related intervention is less likely to be feasible. However, the study done in Zimbabwe did not considered about the health system arrangement to extend incentive benefits to enhance vaccination coverage (Crea et al., 2015).

Another health system arrangement that significantly affects the performance in immunization coverage is the timeliness in immunization coverage. For all types of intervention, whether it is home visits or immunization outreach, the purpose fails until appropriate strategies are not in place for timeliness in coverage. The review of timeliness of immunization coverage is a concern in India, because Barman, Nath & Hazarika, (2015) has showed poor progress in age-appropriate immunization coverage of children due to caste, religion and socioeconomic status of the population in Assam. This implies that timeliness in coverage has been affected by these factors. In the context of Maharashtra, the challenges in timeliness in coverage is reflected by the disparities in coverage in tribal and schedule caste group. The study Mathew, (2012) proved that proportion unvaccinated children was high in four states of India and this was mainly due to imbalance in rural vs urban, girls vs boys, scheduled caste vs others and literate vs illiterate parents. Although Maharashtra had good progress in rural vaccination than urban vaccination, but lower complete vaccination was found in families belong to scheduled caste in the state. This means different in social characteristics of Maharashtra is likely to affect the feasibility of any intervention.

Difference in baseline considerations:

The baseline conditions in any study is also likely to give idea about the effectiveness of interventions. The study included in the systematic review can be evaluated for feasibility in Maharashtra, India by analyzing the relation between baseline conditions and absolute effects. The review of characteristics of included studies has shown that baseline condition was not similar to those of Maharashtra, India in all case. For example, there was an article that focused on evidence based discussion on immunization in poorest districts of countries (Andersson et al., 2009) and another study focused on disadvantage rural community in India for vaccination coverage (Banerjee et al., 2013). However, this is not applicable for the state of Maharashtra because improving immunization rate in rural areas is not their priority. Statistics reveals that immunization rate for rural areas in Maharashtra are good because of good rural infrastructure. Hence, interventions focusing on rural areas stand irrelevant for brining improvement in the context of Maharashtra, India.

Review of studies of cash transfer gave idea about impact of intervention on eligible village community and the education component. This again is not feasible for the baseline condition of Maharashtra (Oyo?Ita et al., 2012). However, on intervention is found to have greater baseline similarity to that of Maharashtra state as it aimed to address immunization coverage in spite of developed immunization infrastructure by means of home visit. This is relevant to the target state because despite the good immunization infrastructure, the state has not achieved equal immunization coverage for scheduled caste group. Hence, use of home visits can be considered an intervention to improve immunization rates. Many others studied focused on pregnant women and endemic areas and this is not related to the context and issues for Maharashtra. The RCT study done in Pakistan can be considered for applicability in Maharashtra as it focused on communities with low literacy and low immunization with use of targeted pictorial messages (Owais et al., 2011). Similar approach might help to improve immunization rates in scheduled caste tribe in Maharashtra.

Insights regarding the implementation of evidence from systematic reviews

The review of the abstract of the systematic review has given idea that there was lack of high certainty evidence regarding any interventions. Petticrew, (2003) mainly suggest that many systematic reviews fail to reach any conclusion because they contain few outcome evaluation or meta-analytic approaches in reviewing of observation data might be missing. In addition, the main problem in deciding the applicability of the interventions for the public health system of Maharashtra India was that studies were done in other country setting apart from India. However, some conclusion can be drawn from this study even if the evidence are not directly applicable for local setting. For example, Owais et al., (2011) was not done in India, however it focused on communities with low literacy and low immunization rate. Hence, some strategies or ideas can be gained from this intervention to address the problem of low immunization rate in schedule caste group in Maharashtra. The intervention focused on immunization promotion educational interventions by trained community health workers and this might help to address perception of immunization in scheduled caste tribe. In addition, the strategy of incentive can be considered in initial stages if the immunization coverage rate is too low in any group. However, in that case. accurate funding arrangements should be there for target groups. Home visits is likely to effective in addressing attitudinal barrier to vaccine uptake. The main gap identified in the systematic review was there was no focus on studies in any racial group and presence of studies in this participant group might be the most feasible for addressing the immunization coverage issues in Maharashtra.


From the critical review of Cochrane review article on intervention to address immunization coverage in low developing countries, the main conclusion is that no intervention is directly applicable for the health care system of Maharashtra, India. However, considering the poor immunization coverage in urban areas and schedule caste tribe of Maharashtra, home visits along with education intervention and incentive is considered to be beneficial for local application  in Maharashtra. Hence, as India is mainly focusing on improving the technologies related to vaccination, there is a need to move to the direction of investment in training of health care professional, education intervention and incentive arrangement to address the challenges in achieving full immunization coverage in Maharashtra. Hence, health of the Vaccination section can focus on investment to extend incentive scheme, increase home visits and improve the quality of immunization education program. 



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