Interventions For Childhood Vaccinations In Punjab, India

The five questions are:

1. Were the studies included in the systematic review conducted in the same setting or were the findings consistent across settings or time periods? 

2. Are there important differences in on-the-ground realities and constraints that might substantially alter the feasibility and acceptability of an option? 

3. Are there important differences in health system arrangements that may mean an option could not work in the same way? 

4. Are there important differences in the baseline conditions that might yield different absolute effects even if the relative effectiveness was the same? 

5. What insights can be drawn about options, implementation, and monitoring and evaluation?

Childhood Vaccination Issue in Punjab, India

Vaccination is critical during early childhood to prevent deadly diseases and infections from happening. There are various countries that lack awareness regarding the importance of childhood vaccination (Dubé, 2015). Health systems prevalent within countries promote vaccination amongst parents of children by various measures. Most important step taken to promote awareness is by providing health cards that contains a host of vaccines at scheduled dates. The scope of the following essay analyses interventions for communities in order to educate or inform regarding childhood vaccinations in Punjab, India. Punjab, India is a middle income developing country, with developed healthcare infrastructure (Mulholland, 2008). Majority of population in Punjab has access to limited education but due to vastness of the state within  country there is low levels of penetration of healthcare systems in suburbs. Suburbs and interior villages of Punjab, which are inhabited by Sikh, Jat and Muslim population experience large gaps in childhood vaccination rates. Aboriginals who are the original inhabitants of Punjab, India are still lacking basic facilities in education and healthcare. There are a number of studies conducted on Aboriginals of Punjab, India that reflects high incidence of diseases amongst their children also high rates of mortality. However, rates of childhood vaccination across citifies and other developed regions highly differs (Garner, 2012). Low awareness and education regarding childhood vaccination can be regarded as a major cause amongst Punjabis. Thus, the aim of this study analyses methods of interventions aimed at several communities especially the less developed Sikh, Jat, Muslim population to educate and inform regarding childhood vaccination.     

Recently there are developed a host of strategies that are being used to communicate with caregivers, parents, communities for informing them regarding child vaccination and improving vaccination (Bhutta, 2010). All strategies are generally aimed at interventions for informing larger communities by way of public meetings, organised events, larger groups, radio, social networking and other methods. There can be at times face-to-face interventions aimed at informing parents of children. Central aim of such interventions includes to educate people regarding vaccination of six years and younger children. These strategies or intervention methods are found to be successful once they have been implemented in targeted areas or focus groups that have low childhood vaccination rates (Engle, 2007). Post era of British colonization, Sikh, Jat, Muslim and other minority people have been experiencing epidemics of infectious diseases, high mortality and morbidity rates. With multiple number of diseases becoming vaccine preventable, Central Government and State Government in Punjab, India are taking measures to  increase levels of awareness and education regarding childhood vaccination. Diseases that were known to cause maximum impact on this segment of the population were tuberculosis, smallpox, influenza, syphilis and measles. These diseases claimed high mortality in the region amongst children especially, main causes attributed to such disease was lower levels of information and lack of knowledge amongst newly settled population (Kaufman, 2012). Childhood vaccination issues has been associated with lower standards of living, poor access to housing, poor access to water and healthcare. Amongst social determinants of health leading to such diseases were low educational outcomes, lack in cultural safety, lack of control over life increases risks of exposure to infectious diseases, with lower rates of vaccination in children.

Strategies to Improve Childhood Vaccination Rates

In recent times vaccination has successful dealt with quite a number of infectious diseases in the region by eliminating rates of vaccine-preventable diseases (VPDs) as tetanus, polio, diphtheria, mums, measles, rubella (Diekema, 2012). Central and State Government has brought about significant improvements in Punjab, India by spreading awareness and improving rates of Punjabi child mortality. In general population VPDs control are at suboptimal levels inspite of high coverage of vaccination in these areas. Invasive pneumococcal disease (IPD) still have high burden of the disease occurring amongst Punjabi and non- Punjabi population. This is a result of Punjabi stereotypes of the vaccine that cannot protect and high levels of environmental exposure (Haines, 2007). Timeliness of immunization is also a major factor that has caused increased incidence of burden of various diseases. Though regularly health centers are conducting programs in areas that have a major population of Punjabi people, yet their reluctances regarding timing of immunization has been the major cause for concern.

Gathering data from Punjabi population, incidence of some diseases were found to be higher compared to others. Therefore, certain vaccinations were recommended for specific usage amongst Punjabi as compared to the non-Punjabi population (Barros, 2012). Range of intervention methods at the communities hence needs to focus on such disease vaccination in consideration to others. Intervention methods that have been found to be effective in the past include varied techniques of one-to-one presentation along with community engagement procedures. With governmental interventions and regular education with information given to Sikh, Jat, Muslim and Punjabi people vaccination levels of children less than five years have    increased substantially (Lewin, 2010). Currently immunization rates of non- Punjabi people in the country are lagging behind Punjabi children vaccination intervention rates. Such high levels of effectiveness has been possible by means of interventions aimed at community to provide education and information regarding the importance of childhood vaccination rates. Central Government has drawn on an Expanded Program of Immunization for Sikh, Jat, Muslim and  started in 1978, which aims at 96% immunization for five year olds and 88% immunization goals for one year old children (DiMaggio, 2011). Immunization along with its appropriate intervention has been recognised to be an important public health since the past 200 years. Aims of children vaccination is to protect vulnerable part of the community, children who are more at risks from infectious diseases. Currently, healthcare centers are working closely with communities to find out innovative ways and methods to reach out. All aims of interventions is to improve access to healthcare services that provides immunization and then to increase more coverage for the same (Flick, 2011). This approach has led to significant results in the domain, w for the Sikh, Jat, Muslims. The health plan with its set target is closing gaps in health by partnering with Punjabi health sector. With differences in baseline conditions there might be some differences in absolute effects and relative effectiveness of rates of childhood vaccination. In case education levels of Punjabi people can be enhanced then there would be tremendous amount of differences in intervention rates effectiveness. With enhanced levels of education, people would be able to perceive and understand information related to effectiveness of such vaccination more effectively (Lieu, 2007).      

Impact of Childhood Vaccination Interventions

The study is aimed at data collection from journals and other secondary sources as internet and newspapers where intervention aimed at communities to routine immunization processes were adopted. There were two groups for the purpose of the study, while one was from Punjabi people other group was from general Punjab, Indian population. Intervention methods aimed at these two locations included in one group meeting with individuals and community members to discuss regarding childhood immunization (Saeterdal, 2014). Other group engaged in procedure that involved seminars conducted regarding the process of costs and benefit approach to childhood immunization process.  

Health arrangement systems does not vary for Punjabi or non- Punjabi population. However, lack of financial capability amongst Punjabi population have hindered their capability to reach out to desired levels of medical attention. Government has made several interventions for subsidizing costs in areas that are large inhabited by Punjabi population. The people as against general Punjab, Indian population can avail such option. However, lack of knowledge or formal education has deterred their capabilities amongst Punjabi people, making them resort to their culturally aligned treatment procedures (Gould, 2009). They generally have been seen to move away from childhood vaccination with complete ignorance of prevalence of diseases. Punjabi people are recommended with scheduled vaccination procedures and charts so that they can timely avail such facilities. The Child Immunization Program a part of the National Immunization Program aimed at free vaccination to children are targeting specifically Punjabi population. The Program provides vaccination to children who are eligible for Medicare benefits and are widely available across Punjab, India. It aims at protecting children who are below the age of 4 years. There are provisions made for missed vaccinations as well (Willis, 2013).  This study aimed at accessing consequences of interventions, as it did not evaluate knowledge in participants of vaccine delivery, confidence of participants in vaccination decision, costs associated with intervention and so on. The government bears significant amount of costs in connection to eradication of diseases that can be prevented by vaccination. With initiatives from Central government there is a tremendous amounts of intervention in the Punjabi population childhood vaccination rates.  

While creating awareness or generating information amongst Punjabi population, it becomes relevant to provide data to access facts and figures regarding mortality or morbidity associated with failure to provide childhood vaccination. Children vaccination has been known to prevent a wide range of illness as well as death. There are a number of reasons that has to be highlighted that creates a gap in children that do not get vaccinated. In case families lack knowledge regarding diseases, which vaccines have capability to prevent, children vaccination might get avoided (Hearing, 2007). Aboriginals have concerns regarding potential harms as against possible benefits that might incur from vaccines, which leads to lower immunization. Parents, caregivers will need to be given face-to-face education through their home visits or by visiting their clinics (Shonkoff, 2012). Cochrane Review also has several literatures that can evaluate the possible impacts of such interventions. In case information is provided to larger groups of community by means of public meetings or through women club, radio or television programs or leaflets and posters or hoardings then greater impact can be generated. It is pertinent to provide education both at the level of caregivers, parents as well as through public meetings. It has been diagnosed that caregivers and healthcare professionals can create tremendous impacts by playing role in early childhood vaccination. Physicians are required to ethically oblige for promotion and protection of health of children. Role of parents centers around having right knowledge and to be able to communicate with pediatrician (Gilmore, 2013). Punjabi people have to be encouraged such that they speak in an open-manner with pediatrician with all possible concerns. Parents needs to be aware regarding subjective and objective information as subjective is something experienced on personal levels. Objective information are those from scientific data, which physician might provide to parents. All discussions has to proceed with a physician that supports vaccination in children and can provide them medically. A physician who withholds vaccination due to personal reasons in unethical manner can harm health of child, parent and the greater community in general. Role of physical has been regarded to most critical in protecting children and providing them appropriate vaccination in a timely manner. Physician can play a great role in providing details regarding vaccination importance and its effectiveness. Physician can also provide effective monitoring and evaluation of vaccination impact. Ethical practices amongst physicians is necessary to promote non-opinion based children vaccination. Physician can educate parents regarding types of viruses, infections along with long-term effects associated with catching them. 

Factors Affecting Childhood Vaccination Rates in Punjab, India

1. In order to gather data from Punjabi population a systematic review was conducted in similar settings as compared to present trends. The time period selected for the purpose of the study was post European colonization to recent periods. In the selected time period methods of interventions, community engagement practices and improvement practices aimed at increasing education or information has been undertaken (Zuckerman, 2009). The intervention of the study whether individual or cluster-randomized and quasi-randomized controlled trails in interrupted time series (ITS) with repeated measure studies that were controlled before-and-after (CBA) studies. The interventions aimed to be conducted across any setting to inform regarding vaccination of children below five years  of age. Interventions were aimed at geographic area of Punjab in India, who have a common cultural and social characteristics. First outcomes from the study were targeted at spreading knowledge amongst people regarding vaccines or vaccine preventable diseases, child immunization status and adverse effects that were unintentional. Secondary outcome from the study were aimed at costs, decision making regarding vaccination and confidence regarding vaccines. 

2. The feasibility of the process was based upon educating and informing regarding childhood vaccination, which depended on ability to communicate effectively and cater to the population or draw their attention to the process. Constraints which can potentially impact feasibility by altering it are timeline and language differences in the region (Labrique, 2013). While it is easier to communicate and interact for intervention to general Punjab, Indians, it differs highly in cases of Punjabi population (Price, 2010). For the purpose of intervention amongst Punjabi population there needs to be method for intervention aimed that can significantly attract attention. An option has to be availed to involve an educated Punjabi person from the population in the health center to cater to aims of the study. On-ground realities associated with belief and faith structures prevailing among Punjabi populations varies significantly that has caused lack of childhood vaccination or immunization. With their own cultural and superstitious belief there might be hindrances encountered to convince them through intervention regarding the importance of childhood vaccination (Noar, 2007). It needs to be ascertained whether there are any differences between on-the-ground realities or constraints which can impact altering feasibility or acceptability of intervention. In case of knowledge regarding vaccination, its benefits and adverse effects to evaluate vaccination services has to be evaluated. Resources that are required for providing of intervention services for communities as transport, materials and locations needs to be analysed.    

3. With health systems aimed at providing information and education pertaining to children vaccination such that individuals can take informed decisions regarding health. Through appropriate interventions knowledge and education can be imparted that can change their attitudes regarding vaccination along with diseases that can be prevented. There are contextual level of differences that encompasses socio-cultural systems along with health system factors. Personal perception of vaccines might differ amongst individual and group influences of a vaccine.  Meaning specific issues pertaining to vaccination as individual assessment of risks along with potential benefits might result in differing option that could not work in similar manner. As a key barrier in health systems amongst obtaining information pertains to poor understanding related to people in Punjab region. Knowledge  of health systems along with their roles and effectiveness have to be understood properly for proper decision making and risk taking. In Punjab decisions pertaining to childhood vaccination is dependent on trust and personal experience factors.      

4. Baseline conditions might vary significantly with rising differences in absolute effects and relative effectiveness. In cases of absolute effects there might be no intervention created on the trail group. Results in relative effectiveness group on the other hand might arise from intervention arising from interventions made (Granum, 2013). Though there was a minimum level of gaps that existed but long-term impacts associated with absolute conditions are higher compared to relative group.    

5. WHO as well as local health provider authorities have set up monitoring and evaluation standards aimed at generating outcomes or results for childhood vaccination. With implementation of program at the Centre level in India and specially in Punjab, there needs to be counting program incorporated. Every health centre will report number of child births and a schedule of vaccination will also be maintained along with it to check for monitoring. Implementation of the program will be done at National level and at regional level to ensure proper figures and childhood vaccination accountability. Ascertaining  of resource involved for the purpose of immunisation delivery would also ensure that standards are implemented and steps are taken for interventions. More applicable monitoring and evaluating standards for childhood vaccination is GRADE. It is a measure scale used for accessing outcome for evidence amongst low to moderate data available. GRADE profiler software (GRADEpro 2008) is use in reviewing of primary outcomes for comparison with estimated related effects. It can be used to include number of participants along with  contributing data in regards to those outcomes. There are other formats to measure outcomes amongst population with various levels of data as well.

There are potential biases associated with communication interventions in electronic databases. Thus in order to overcome the challenge a large number of literature sources were searches to include a broad range of terms, concepts. Cochrane Review is used for assessing data in face-to-face intervention methods.  Review of the study reflect that educating parents face-to-face regarding childhood immunisation might have little or no impact on the child’s immunisation status. Though, intervention might actually improve attitude of persons towards vaccination, it might not engage mothers in decision making for vaccination.   There is thus moderate to high likelihood that effect will be different compared to interventions results.     

Conclusion 

Analysis from above facts and figures regarding education or information interventions to communities clearly states usage of various methods. While educating and information giving encompasses a continuous method for increasing overall awareness amongst various participants in the community, healthcare centers needs to identify certain important life taking diseases. Medical centers that have facilities of child birth needs to hand over the key vaccination lists of BCG, Hepatitis B & C, Rubella and other diseases to which the child is extremely vulnerable to. Central government and state government needs to function hand in hand to ensure that such vaccinations are provided to children post their birth at regular intervals provided. A record of parents of newly born children as well as children under the age of 6 years has to be maintained such that intervention aimed at information can be made successful. Providing information regarding childhood vaccination will let improve attitude towards vaccination, which might result in eventually taking the vaccine under circumstances. As there are lots of belief regarding vaccination in Sikh, Jat, Muslim population, strategy aimed at informing them has to be heightened. But, major challenge in communicating strategies that might lead to increased vaccination intake might lead to high amounts of resources consumptions once implemented on a large scale. Therefore, healthcare facilities need to draw up a plan for action and submit it for prior funding and approval from Central and State governments. There might be also challenges pertaining extensive evaluation that might be required. With proper monitoring and evaluation such strategies might gain tremendous impetus to grow and develop.   

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