Redesigned immunization card and center-based education to reduce childhood immunization dropouts in urban Pakistan: A randomized controlled trial

Abstract

In Pakistan during 2000–2004, about 11–13% of children who received the first dose of diphtheria–pertussis–tetanus (DPT1) failed to complete its third dose (DPT3). We assessed the effect of a redesigned immunization card and center-based education to mothers on DPT3 completion. We enrolled 1500 mother–child units at DPT1, randomized them to three intervention and one standard care groups, and recorded their DPT3 visits during a 90-day follow-up. In multivariable analysis, a significant increase of 31% (adjusted RR = 1.31, 95% CI = 1.18–1.46) in DPT3 completion was estimated in the group that received both redesigned card and center-based education compared with the standard care group.

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.