7. Immunization programmes
Target Group/Country Communities in two urban settings in of Addis Ababa, Ethiopia
Intervention Methodology Use of a reminder sticker in reducing immunization dropout rates. The sticker was circular with a picture of a child receiving vaccination and an appointment date on it with the name of the month written in Amharic. The mothers were instructed to apply the sticker to the inside of their home front door. Both groups received health education individually. The health education took approximately 10 minutes for both intervention and control groups. Explanation of the sticker took and additional 1 minute for the intervention group only.
Evaluation method A total of 703 children were entered into the study. The intervention days and non-intervention days were randomly selected and caretakers were recruited on arrival at the vaccination centres for their first DPT dose between 6weeks and 23 months. The intervention group received a reminder sticker and the control group did not. All other services were identical. A baseline interview using a closed ended questionnaire was given which documented the socio-demographic and maternal characteristics potentially related to immunization services. Children who did not return for the second injection after 8 weeks (4 weeks was the recommended time period) were classified as dropouts and reasons for not attending were determined through a questionnaire.
Impact Achieved The dropout rates were 7.3 and 13.3% in the intervention and control groups respectively. This difference is clinically and statistically (P < 0.01) significant. On supplying reasons for not bringing children for immunization 11of the control mothers gave unawareness of the need for a follow-up dose as the main reason while none of the intervention mothers did so(p<0.01). Therefore, it is concluded that the reminder sticker is effective in reducing immunization dropout rates. However the authors draw attention to the urban setting and relatively better off nature of the community which may affect the success of the method in other communities.
Berry, D.J., Yach, D. and Hennink, M.H.J. (1991) An evaluation of the national measles vaccination campaign in the new shanty areas of Khayelitsha. S. Afr. Med. J. 79, 433-436.Ref ID : 6856
Target Group/Country A community undergoing rapid urbanisation near Cape Town, South Africa
Intervention Methodology The 3 week intensive campaign used stickers, pamphlets, posters, radio, newspapers and enlisted the help of community leaders. Actual vaccination activity was divided into two phases. The first involved all available staff based at fixed clinics and in the community using two mobile units equipped with loud hailers. If no "Road to Health Card" was available, a new, specially coloured card was issued. Any child between the age of 6 months and 5 years without documentation of vaccination was given measles and/or polio vaccine. Community health workers, student nurses and health inspectors all contributed to this phase. A second campaign was planned but low staff moral due to the increased workload of doing the campaign and immunizing children together with the rainy season led to a lower key "mopping up operation" details of which are not provided.
Evaluation Method Four serial cross-sectional cluster samples were used. The 1st (n=206) was before the campaign, the 2nd (n=175) following the 3 week campaign, the 3rd (n=350) was 2 months after the campaign and the 4th (n=205) was 6 months after the campaign. The proportion of the children vaccinated at the time of the campaign was estimated by defining a campaign vaccination as one given either during the dates of the official campaign or having the abbreviated date stamp of the campaign.
Impact Achieved Proven vaccination coverage before the campaign was 55,8%% (95% confidence interval (CI) 46-66%), immediately afterwards it was 71.1% (95% CI 65-77%) and 6 months later 73.6% (95% CI 67-80%). In surveys 2 and 3 the proportion of the children fulfilling the criteria of being vaccinated during the campaign was 25.8% (95% CI 29.3%). By survey 4 this proportion had fallen to 6.8 (9.5% CI 3.9-9.8%). Significant determinants of vaccination coverage were: place of birth (chi squared = 9.7; 2df; p=0.008; CI 1.2 -4%; and home birth (OR 3.21; 95%CI 1.2-8.4%). A group that posed a particular problem for sustaining vaccination levels was the incoming Transkei-born children, The authors discuss their findings in the light of debates concerning the value of campaigns versus routine services.
Duque, L.F., de Bello, P.V., Bejarano, J., Ruiz, A., Rodriguez, W., Silva, E., Jaramillo, G., Munoz, A.L., Gacharna, M., Pacheco, C. and Rivera, L. (1984) Ref ID : 8381The national vaccination crusade in Colombia. Assignment Children 65/68, 159-178. Ref ID 8381 (Borderline for inclusion in database)
Target Group/Country Parents in Colombia
Intervention Methodology The National Vaccination Crusades in Colombia involved three intensive vaccination days ( 23rd June, 28th July and 25th August 1984) with an aim to vaccinate nearly a million children against diptheria, whooping cough, tetanus, poliomyelitis and measles. carried out throughout the country. The programme had the strong official endorsement of the Crusade by the Head of State, the existence of a political will and exceptional media support (press, television and radio), all sectors of society, both public and private, joined forces and cooperated and 10,000 vaccination posts throughout the country were mobilized The programme provides a good example of the use of the campaign and social mobilisation approach involving schools, churches and many other sectors..
Evaluation Method Details on vaccinations given were recorded by the health information system (no information provided in this report)
Impact Achieved In three vaccination days it was possible to vaccinate nearly a million children (over 90%) of the target against five communicable diseases: diphteria, whooping cough, tetanus, poliomyelitis and measles. On 23rd June and 28th July the numbers of children vaccinated were 804,053 and 854,570 respectively. The Colombian programme was the first ever use of such intensive one day campaigns at which three vaccines were simultaneously administered throughout a country. While demonstrating the ability of one day intensive programmes to immunize children, it would have been useful to have had some information on the costs involved, potential spin-offs and some discussion of the sustainability of such intensive campaigns. While presenting data on immunization coverage, this report provides little information on the source of the data and other supporting information on the effectiveness of programme inputs.
Jallah-Macauley, R. and Bender, D.E. Improving vaccination completion rates in Liberia: evaluation of an intervention trial. International Quarterly of Community Health Education 11(4):333-344, 1990. Ref ID : 4382
Target Group/Country Communities in Bomi and Cape Mount Counties in coastal Liberia, West Africa
Intervention Methodology A community-based strategy employing local chiefs and traditional midwives as extenders of the Ministry vaccination team for the purpose of increasing vaccination completion. The intervention strategy consisted of a two day training workshop (one for chiefs and the other for traditional midwives -TMs i.e. traditional birth attendants) and two subsequent supervisory visits. In the workshops general information regarding the purpose of the vaccinations was shared and the Chiefs and TMs were asked for their assistance in achieving 100% immunization coverage. Large pieces of paper were supplied to make roster boards in which villages could record the immunization status of every child in their community. Visits by the mobile vaccination team for the second and third rounds of vaccination were held typically in the dry season - typically the mobile unit visits 2 to 5 villages per week.
Evaluation Method Four districts in each of two counties were randomly assigned to one of four categories: 1) Chiefs only; 2)midwives only; 3)chiefs and midwives; and 4) control. Evaluation of the intervention was carried out after an eight-month follow-up period. Visits to intervention and control villages, for the purpose of interviewing chiefs, TMs and mothers of children under one year of age, were the means by which data were gathered. Both process and outcome indicators were identified as means of assessing the effectiveness of the strategy. Vaccination rosters and holding of a town meeting were used as evidence of the former. A vaccination coverage survey of 346 children using a cluster sample methodology was used to evaluate differences in vaccination coverage..
Impact Achieved 55% of children from intervention villages had completed their vaccinations compared to only 45.5% from control villages (p=0.015). Comparison of the village rosters against the vaccination coverage survey data96% (24 of 25 sets) of records in Grand Cape Mount County were found to be in agreement. 92% of the chiefs and TMs had held a meeting to discuss vaccinations with the townspeople on return from the workshops. 95% of the chiefs and TMs knew that a child is not protected by one vaccination (p<0.001) and only 30% of controls knew this. In intervention villages 69% of mothers who knew the importance of vaccinations had completed their child's vaccinations (p=0.007) and in the control villages there was no significant relationship. In intervention villages , those mothers who knew that a child is not protected after one dose of vaccine were more likely than mothers in control villages to have completed the child's vaccinations (58% vs 48%, p=0.038). 79% of the chiefs and TMs could describe the correct management of vaccination sore compared to only 40% of controls (p<0.02) When stratified by type of leadership, coverage rates were higher in intervention districts where TMs rather than chiefs served as vaccination team extenders (p=0.015), although chiefs were more effective than controls
Khanom, K. and Salahuddin, A.K. A study of an educational programme on immunisation behaviour of parents. Bangladesh Med.Res.Counc.Bull. 9:18-24, 1983. Ref ID : 1008 (Borderline for inclusion in database)
Target Group/Country Families in the study area of Dhania, Rasulpur,Bangladesh.
Intervention Methodology Group discussion with locally influential leaders re immunisation. The study area divided into three blocks. Group discussions (one for male and one for female) held in each block. 45 mothers and 30 fathers attended. Information given was the same for all groups. Educational aids: posters, leaflets and charts. 25% of the population attended a film show. Families of un-immunised children were visited and health education given.
Target Group/Country Intervention study, with pre and post assessment by interview of 100 families selected by simple random sampling. : Interview of sample families.
Impact Achieved Knowledge of symptoms of six diseases increased: diphtheria: 33%, pertussis: 26%, tetanus: 34%, measles: 30%, poliomyelitis: 37% and tuberculosis 23%. The mean percentage of correct responses was 66.5%. Knowledge about vaccines available to prevent these diseases increased: DPT: 32%, BCG:30%, Measles: 27%, Polio: 30% - mean percentage of correct responses 34.7%. Knowledge about EPI immunisation schedule increased: DPT: 44%, Polio: 42%, BCG: 38%, Measles: 24% - mean percentage of correct responses 38.5% Attitude of parent towards immunisation: Post intervention 100% agreed immunisation of children necessary ( 23% increase) and 95% said they would take their children for immunisation (54% increase). None of the participants knew of the measles vaccine prior to the health education intervention. Post intervention the overall percentage of knowledgable persons in the sample remained low. In the 100 families 119/147 target children were not vaccinated. The main reason for nonacceptance were: perceived carelessness of the health provider by parents (43%); ignorance of parents regarding vaccines (27%); and non availability of vaccines (16). The lack of controls and significance testing severely limit the value of this study.
Reyes,H., Pego,U., Tome,P., Ceja,K., Flores,S. and Gutierrez,G. (1999) Immunization
promotion activities: are they effective in encouraging mothers to immunize
their children? Soc. Sci. Med. 49, 921-932. Ref
Target Group/Country Mothers of pre-school children in Mexico
Intervention Methodology The National Vaccination Council (CONAVA) launches three immunization campaigns for mostly polio and measles every year. This study refers to the Second National Health Week (SNHW).Vaccines are provided at health facilities, temporary health posts and through home visits and this is combined with distribution of Vitamin A, albendazole and oral rehydration salts. Messages targeted at both adults and children are broadcast on radio and television. Most of the messages are based on popular children's songs or slogans. TV spots use cartoons or animated clay figures. In addition posters, flyers, newspaper ads and announcements are distributed through communities in key public places. Private companies, NGOs and schools participate in the campaign - notifying parents of the campaign. Face-to-face motivation of mothers was also given by health workers or volunteers at the immunization posts or during home visits
Evaluation Method A probability sample of 935 mothers living in the metropolitan area of Mexico City and having at least one child under five years old was selected for the study. Mothers were interviewed one month after the campaign to determine four outcome variables: (1) mothers' knowledge about the SNHW; (2) mothers' comprehension indicating how well they understood the campaign messages (aware, partly aware and unaware) Mothers who remembered that the campaign aimed to provide either polio or measles vaccine or both were defined as 'aware'; (3) mothers' motivation, i.e. whether or not they sought out immunizations for their children under the age of five and (4) mothers' opinion of how well they liked the messages. There were no controls or baseline
Impact Achieved 601 (64.3%) were knew that the campaign aimed to provide immunizations and were defined as 'aware'. 224 (24%) knew about the campaign but not that it was about immunization - 'partially aware'. 110 (11.75%) did not know about the campaign - 'unaware'. Among those aware mothers, 526 (87.5%) of their children received immunizations, 379 (72.1%) voluntarily and 147 (27.9%) through face-to-face motivation. Of the unaware mothers' group, fewer (80, 72.7%) of their children received immunizations; of those fewer (50, 62.5%) of the mothers took their children or their own accord and a higher proportion (30 - 37.5%) - acted because of face-to-face motivation. The proportion of 'unaware' mothers not taking their children for immunization was significantly higher (p<0.05) and more than double (30 - 27.3% of 110 ) that of 'aware' mothers (75 -12.5% of 601). The campaign had more impact on mothers of lower socio-economic level which may be because higher socio-economic mothers made more use of private health services for immunization.
Quaiyum, A., Tunon, C., Baqui, A.H., Quayyum, Z. and Khatun, J. (1998) Impact of national immunization days on polio-related knowledge and practice of urban women in Bangladesh. Health Policy and Planning 12, 363-371.Ref ID : 7246
Target Group/Country Women in Dhaka, Bangladesh
Intervention Methodology National lmmunization Days (NIDs) from 1995 as part of the country's goal to eradicate poliomyelitis by the tum of the century. The NIDs brought together government agencies, the media, voluntary organisations and individual volunteers in social mobilization and service delivery activities
Target Group/Country Data were collected through pre- and post-NID cross-sectional surveys in a sample of one area of Dhaka city which included slum and non-slum households. Knowledge data were collected from 525 women with at least one child aged less than five years. The oral polio vaccine (OPV) coverage during NIDs was obtained from 720 children
Impact Achieved Knowledge of polio as a vaccine preventable disease increased after NIDs among both slum and non-slum women (p<0.05). The knowledge gap between the slum and non-slum dwelling groups of women was significantly reduced. Field workers, who regularly visit women at their homes to promote health and family planning services, were the main source of information for the slum women while television was cited as the most important source of information by non-slum women (p<0.005). The study revealed that 88% of children under five years received at least one dose of oral polio vaccine (OPV) during NIDs, and 67% received two stipulated doses with no significant differences between slum (65%) and non-slum (69%) groups. In addition, 68% of the children contacted during the NIDs were given vitamin A supplementation. This shows the benefits of linking other interventions such as Vitamin A with immunization programmes. The differential access to communication also shows the need to target communication strategies to the specific needs of target groups.
Risi, J.B. (1984) Nation-wide mass polio immunization in Brazil. Assignment Children 65/68, 137-157.Ref ID : 8382 (Borderline for inclusion in database)
Target Group/Country Parents in Brazil
Intervention Methodology In response to the lack of success of routine immunization, mass immunization programmes based two one-day immunization campaigns per year were launched in 1980. A strong political determination, large-scale community involvement of all sectors of society, the assistance of over 450,000 volunteers, a national distribution of tasks and efficient coordination at all levels were identified as some of the crucial components
Evaluation Method Data on immunizations carried out during the one day campaigns were collected for the 8 days from 1980 to 1983. There were no controls.
Impact Achieved Nearly 20 million children were immunized at each one-day campaign. Between 1975 and 1980 an average of almost 2330 cases of poliomyelitis were reported annually in Brazil representing a rate of 2.1 cases per 100,000 inhabitants. In 1981 only 122 cases were registered giving an incidence of 0.1 cases per 100,000. Whilst provided striking information on the benefit that can result from such a campaign, a weakness of this report is the lack of any research which ascribes the importance of specific programme inputs and any discussion on issues of sustainability and cost.
Shepard, D.S., Robertson, R.L., Cameron, C.S.,3d, Saturno, P., Pollack, M., Manceau, J., Martinez, P., Meissner, P., and Perrone, J. Cost-effectiveness of routine and campaign vaccination strategies in Ecuador. Bull.World Health Organ. 67(6):649-662, 1989. Ref ID : 5848
Target Group/Country Children in Ecuador
Intervention Methodology A major purpose of the campaigns was to complement the routine services and to accelerate immunization activities. Details are not provided of the content, timing and other programmatic details for the campaigns described.
Evaluation Method A national household coverage survey of 3697 Ecuadorean children, carried out in July 1986, provided an opportunity for a cost-effectiveness analysis of (1) routine vaccination services based in fixed facilities and (2) mass immunization campaigns.
Impact Achieved The campaigns, though less cost-effective than routine services, significantly improved the vaccination coverage of younger children who had been missed by the routine services. The costs per fully vaccinated child of both the campaign and the routine services compare favourably with the Program for Reduction of Maternal and Childhood Illness (PREMI) and earlier campaigns increased the proportion of children under 5 years who were fully vaccinated from 43% to 64%. In one year, the PREMI campaign was responsible for fully vaccinating 11% of children under one year, 21% of 1-2-year-old children, and 13% of all children under 5 years. The campaign also helped ensure that vaccinations were completed when children were still very young and at greatest risk. The average cost per vaccination dose (in 1985 US$ prices) was approximately $0.29 for fixed facilities and $0.83 for the PREMI campaign. Total national costs were $675,000 and $1,665,000 for routine and campaign services respectively. The cost per fully vaccinated child (FVC) was $4.39 for routine vaccination services and $8.60 for the campaign. The cost per death averted was about $1900 for routine vaccination services, $4200 for the PREMI campaign, and $3200 for the combined programme.
Zeitlyn, S., Rahman, A.K., Nielsen, B.H., Gomes, M., Kofoed, P.L. and Mahalanabis, D. (1992) Compliance with diphtheria, tetanus, and pertussis immunisation in Bangladesh: factors identifying high risk groups. B. M. J. 304, 606-609. Ref ID : 2776 (Borderline for inclusion in database)
Target Group/Country Urban mothers in Dhaka, Bangladesh
Intervention Methodology All children received their 1st dose of the vaccine against diphtheria, tetanus, and pertussis and health workers gave education to mothers using small group discussions, individual counselling and visual aids. Messages included the nature of the diseases that vaccinations protect against were explained and the need for a second dose four weeks later and 3rd and 4th visits to complete the vaccination course were emphasised.
Target Group/Country This cohort study of infants included 136 unimmunized children ages 6 weeks-23 months who lived within reach of the treatment center. 1st doses of the vaccination were given immediately followed by an interview to measure knowledge about immunization. This was followed up with a second interview 6 weeks later to ascertain compliance with having the 2nd dose. At the 6-week follow-up, 16 of the children could not be traced and 7 had died.. Interviews were carried out Rate of non-compliance with advice to return the child for 2nd vaccination was the main outcome measure. There were no controls.
Target Group/Country 46 of 113 children (41%) received the 2nd vaccine dose. Factors most closely associated with maternal failure to comply with 2nd dose were lack of education and low income. Children whose mothers know most about immunization at 1st interview were more likely to have their 2nd dose. The authors suggest that further research needs to be aimed at ways of making health education more effective among uneducated parents and that such health education programs need to be targeted at those who are non literate and do not own television or radios. In the absence of controls it is difficult to attribute any impact to the implementation of the educational programme. It is also unfortunate that so little information is provided on the nature of the health education input - it would have been useful to have had some observational study on the quality of the health education to suggest ways in which it might be improved.
Zimicki, S., Hornik, R.C., Verzosa, C.C., Hernandez, J.R., de-Guzman, E., Dayrit, M., Fausto, A., Lee, M.B. and Abad, M. (1994) Improving vaccination coverage in urban areas through a health communication campaign: the 1990 Philippine experience. Bull. World Health Organ. 72, 409-422. Ref ID : 2132
Zimicki,S. and Hornik,R.C. (1997) Explaining the impact of a communication campaign
to change vaccination knowledge and coverage in the Philippines. Health Communication
Ref ID: 8942
Target Group/Country National programme in Philippines
Intervention Methodology The Philippine Department of Health conducted national mass media communication campaign during the period March-September 1990 to support routine vaccination services. City mayors, health officers and clinic staff primed for campaign ( conferences, meetings etc.). Mass media campaign, four television and four radio advertisements broadcast. Messages: the danger of measles and its complications, recommendation that infants 9-12 months to be taken to health centre for vaccination. Advertisements printed in newspapers with the message that Wednesdays were free vaccination days. Other promotional materials: posters, welcome streamers, stickers, T-shirts. Materials emphasised that vaccinations were free and available on Wednesday at health centres. Campaign slogan "Protect your baby from measles".
Target Group/Country A two phase communication campaign (pilot and intervention) with pre and post campaign surveys (1989 and 1990). : 1)A post campaign survey was conducted 5 months after start of the campaign using a structured questionnaire and multistage cluster sampling (cluster size 10, sample restricted to less well off people). Families included those with children < 2 years. Coverage estimates based on carers reports and vaccination cards. 2)Simultaneous health centre survey: Structured interviews with staff of 60 health centres, observation of 10 children attending a subset of 20 health centres on vaccination days and exit interviews of adults in same health centres
Target Group/Country There was a significant increase in knowledge of measles vaccination (P<0.01) and some increase regarding other vaccinations. However, the relationship between knowledge and practice remained the same between 1989 and 1990. There was "little evidence for changes" in the way that vaccination sessions were held in the health centre. While the proportion of exit interviewees saying that "someone explained about vaccination" increased from 18.4% (1989) to 75.5% (1990) this was not paralleled by an increase in their knowledge. Percentage of fully vaccinated children increased from 54% (1989) to 65% (1990), P < 0.0001. Percentage of children < 4 months who had at least one vaccination increased from 43.3% 1989 to 55.6% 1990 (Rate difference 12.3%, 95% CI 1.5-19.0). Percentage of children ages 2-8 months with at least four vaccination increased (47.7% 1989 to 56.2% 1990 (Rate difference 8.5%, 95% CI 0-17.1). Percentage of children aged 9-11 months who had all vaccinations increased (32.2% 1989 to 56.2% 1990. rate difference 24.0, 95% CI 12.2-35.8). Factors contributing to the success of the campaign: good public access to the media (radio 73%, television 60%, both 50%), the development of high quality radio and television spot and a routine system ready to serve the increase in demand the campaign generated.
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