Redesigned immunization card and center-based education to reduce childhood immunization dropouts in urban Pakistan: A randomized controlled trial
Introduction
In most World Health Organization (WHO) member states, the Expanded Programme on Immunization (EPI) provides a series of childhood immunizations during the first year of life against tuberculosis (BCG), diphtheria–pertussis–tetanus (DPT), polio (OPV), measles, and hepatitis B virus (HBV). In Pakistan and many other WHO member states, the EPI childhood immunization schedule includes the administration of BCG/OPV vaccines at birth, three doses of DPT/OPV/HBV vaccines at 6, 10, and 14 weeks and measles vaccine at 9 months after birth. The completion of three doses of DPT (DPT3) vaccine is reported as the principal indicator of immunization coverage levels by the WHO [1].
From 2002 to 2004 in Pakistan, BCG immunization coverage was recorded at 80–82% and DPT3 coverage at 65–68% [2]. The Eastern Mediterranean Region (EMR) and the South-East Asia Region (SEAR) have consistently achieved higher immunization levels than has Pakistan. In Pakistan during 2000–2004, about 15–26% of children who received BCG failed to complete Measles immunization. Similarly, about 11–13% of children who received DPT1 failed to complete DPT3 immunization. These dropouts have been among the highest worldwide [3], [4]. Most countries of the African Region (AR) face the same challenge of dropouts [2].
The EPI in Pakistan is implemented through a countrywide network of EPI centers and outreach programs in some areas. Mostly, mothers/caregivers (here forth simply referred to as “mothers”) from the lower and middle socioeconomic tiers of the country receive immunization at EPI centers whereas more affluent mothers prefer the private sector. The current BCG coverage (∼80%) suggests that the majority of newborns visit the EPI centers for BCG vaccinations. However, a substantial proportion does not manage to complete the immunization schedule as indicated by much lower DPT3 and measles coverage. Both parental (larger family size, lower parental education, mother's lack of knowledge and motivation) and provider factors (distance of EPI center from home) reportedly affect immunization schedule adherence [5], [6], [7], [8]. Lack of information and motivation for subsequent immunization visits has been identified as the main reason for dropouts in developing countries [9], [10], [11].
In Pakistan, a small EPI card is used (9 cm × 8.5 cm, when folded) that contains information on the child identification; immunization schedule; information for mothers; and next immunization visit dates. All this information, cluttered on a small card, can make it difficult for generally less literate mothers to locate the item most relevant for them, i.e. their child's next immunization date. In addition, the next immunization date is hand written and often in such small and irregular letters that it further amplifies the difficulty for mothers to read it. Also, mothers sometimes misplace the EPI card in their homes. In addition, there is no standard information sharing routine with mothers at the EPI centers about subsequent immunization visits.
In industrialized countries, multi-component interventions including center-based education to mothers have led to significant reduction in immunization dropouts in several studies [12], [13]. In these settings, patient reminders alone [14] or in combination with other strategies [15], [16] have also been effective in reducing dropouts. Unfortunately having in place a comprehensive and efficient immunization registry is a prerequisite for these resource intensive methods of client reminder; hence they may not be feasible in a developing country like Pakistan.
It is critical to design and test innovative interventions to improve immunization schedule adherence in low-income countries such as Pakistan, and evaluate their effectiveness and suitability for large-scale implementation. To this effect, we designed a randomized controlled trial to assess the effect of providing redesigned immunization card and/or center-based education to mothers on DPT3 completion. The main objective of this study was to assess the effect of (1) a redesigned immunization card, (2) a center-based education to the mothers, and (3) the redesigned immunization card with the center-based education to mothers on DPT3 completion at urban EPI centers in Karachi, Pakistan.
Section snippets
Setting
This randomized controlled trial was conducted at EPI centers located in urban areas of Karachi city. One EPI center was selected from each of the five administrative districts of Karachi. These immunization centers were housed in government dispensaries and basic health units providing primary health care to the urban population in their catchment areas.
Eligibility and enrollment
Study participants were enrolled simultaneously from all the five EPI centers. All children visiting the selected EPI centers for DPT1
Results
Between 6 September and 24 December 2003, a total of 1500 mother–child units were enrolled in four study groups from five EPI centers. We enrolled 300 participants, 75 in each of the 4 study groups, from each EPI center. Finally, we had 375 study participants in each of the 4 study groups (Fig. 1). We completed the follow-up of study participants at the EPI centers on 23 March 2004. No study participant was lost to follow-up since the study participants not returning for either DPT2 or DPT3
Discussion
This study suggests that providing an inexpensive well-designed immunization card and education to mothers at EPI centers are effective and pragmatic strategies to reduce childhood immunization dropouts. In this randomized controlled trial, a significant improvement in childhood DPT3 completion was recorded in groups of mothers who received either redesigned card or center-based education or both redesigned card and center-based education compared to standard care only group.
In developing
Acknowledgments
Neil Halsey of Johns Hopkins Bloomberg School of Public Health and Anthony W. Mounts of Centers for Disease Control and Prevention (CDC), Atlanta is gratefully acknowledged for reviewing the manuscript. We also thank the EPI Sindh, Pakistan for granting permission and extending cooperation for this study.
This study was funded by the University Research Council (URC) of the Aga Khan University, Karachi. The funding agency had no role in study design, data collection and analysis, decision to
References (39)
Pediatric vaccine compliance
Pediatr Clin North Am
(2000)- et al.
A model immunization demonstration for preschoolers in an inner-city barrio, San Diego, California, 1992–1994
Am J Prev Med
(1996) - et al.
Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program
Am J Med
(1990) - et al.
The effects and costs of expanding the coverage of immunisation services in developing countries: a systematic literature review
Vaccine
(2005) - WHO vaccine-preventable disease: monitoring system. 2006 Global summary;...
- WHO vaccine-preventable disease: monitoring system. 2004 Global summary. Regional immunization profile;...
- Review of national immunization coverage 1980–1999. Pakistan: WHO/UNICEF; 2001...
- The progress of nations 2000. The power of immunization. UNICEF;...
- et al.
Factors responsible for delayed immunisation among children under 5 years of age
J Indian Med Assoc
(2000) - et al.
Factors predicting the non-utilisation of immunisation services using logistic regression technique
Indian J Pediatr
(2000)
Factors affecting acceptance of immunization among children in rural Bangladesh
Health Policy Plan
Evaluation of vaccination coverage
Indian J Pediatr
Moderate immunization coverage levels in East Delhi: implications for disease control programmes and introduction of new vaccines
J Trop Pediatr
An evaluation of routine immunization coverage in some districts of West Bengal and Assam
Indian J Public Health
The impact of the standards for pediatric immunization practices on vaccination coverage levels
JAMA
Computer reminders improve on-time immunization rates
Med Care
Improving influenza vaccination performance in an HMO setting: the use of computer-generated reminders and peer comparison feedback
Am J Public Health
Easy SAS calculations for risk or prevalence ratios and differences
Am J Epidemiol
Prevalence proportion ratios: estimation and hypothesis testing
Int J Epidemiol
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2023, Cochrane Database of Systematic Reviews
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