The health strategy meant for the improvement of child survival through fighting killer diseases is Immunization. Every year millions of children belonging to the low and middle income countries do not get the full doses of required vaccine as mentioned in the national routine for immunization schedule. The essay is a discussion on the Cochrane review published in the year 2011. The review mainly focuses on the interventions on improvement of immunization for children in the low and middle-income countries (LMICs). The objectives of the essay is to ensure effective evaluation of interventions strategies for sustaining and boosting high coverage of immunization for children in low and middle income countries.
The Cochrane review is done with the aim to evaluate the impacts of the various intervention strategies for increasing the number of immunized children from prevention of infectious disease in LMICs. Therefore, researchers in Cochrane analyzed and collected the relevant studies to find an answer, and finally concluded with 14 studies that were relevant (Oyo-Ita 2016). Although strategies for improving childhood vaccination does not work much but initiatives like providing information about the importance of the vaccine to the community members and the parents does make a difference. There should also be provisions for specially designed cards for vaccination reminder, rewards and identification of children yet to be receive a vaccine and sending them to health clinics on an immediate basis can drive more children to receive a vaccination in LMICs. Integration of immunization service to other services can also lead to the improvement of the scenario. In this context, it can however be said that offering money to the parents for vaccinating their children in the middle and low-income countries will not lead to an improvement in the scenario. Majorly the findings are not certain and therefore there is a need for research in this area that needs well conduction.
The studies eligible for the incorporating the intervention strategies for increasing the number of immunization for children in the middle and low- income countries were based on randomized controlled trials, also known RCT, controlled before and after studies, non RCT and interrupted time -series that mainly included caregivers, children between the age 0 to 4 years, providers of healthcare. However, for the data analysis there was independent screening of the output found through research, full text review of articles that were eligible, assessment of risk bias and solving discrepancies through consensus. Finally, random affects Meta analyses used for accessing the certainty of the evidence.
The inclusion criteria involved conclusion from 14 studies, 10 of which were RCT cluster whereas there were four individual RCT. There was one study each from countries like Ghana, Honduras, Georgia, Mali, Mexico, Nicaragua, Zimbabwe and Nepal that was used as inputs. In addition to this, there were two studies from India and four studies from Pakistan (Oyo-Ita 2016). The risk bias for one study was unclear while the thirteen other studies had high-risk bias. Out of 14 studies, three studies each involving evaluation on health education based on community and facilities, three studies on household incentives, one study each on outreach sessions for regular immunization, supportive supervision, home visits and one study each on supportive supervision, information campaign and integration of immunization services for malaria prevention.
PICOT Table i.e., the ‘Methods for Considering Studies for the Review’.
The patients considered here are the children of the low and middle income countries
Intervention (For intervention studies only
The study on Cochrane review aims at evaluating the impact of intervention strategies for increasing the vaccinated children in the LMICs and thereby preventing them from deadly infectious diseases. Therefore, therefore researchers of Cochrane analyzed and collected data to find an answer to the number of children unvaccinated and the importance of intervention required for improving the scenario. In this regard, they were able to find 14 studies that were relevant.
Informing and discussing the importance of vaccination with the village community members and the parents can increase the children receiving vaccines for diphtheria tetanus and pertussis (DTP).
Further, during visits to the health clinics, the parents made aware through reminder cards or integration of vaccinations with other health services. This may compel them to complete all the three doses of DTP for their children
Moreover, offering money to parents for vaccinating their children can also make a difference. Sometimes financial crisis forces the parents to opt out vaccination for their children. However, the percentage of children vaccine through money aids would be less as the money used for fulfilling other necessities.
Engaging outreach teams for offering vaccinations to children on a monthly basis can improve the number of children getting vaccine.
Outcome of Interest
Increasing the percentage of children getting three doses of DTP vaccine
Integrating immunization with other services of healthcare for better results among children
Increase the section of the children receiving all the necessary vaccines by the age of two mostly in the middle and low income countries
The research however found that there were chances of moderate certainty on improvement of the vaccination scenario even when proper information about the vaccination conveyed to the parents. Further, the chances were low even in cases when people or parents made aware about the importance of vaccination while regular health visits or through integration of vaccine service with other services related to healthcare. Even the monetary aid provided low certainty in improving the vaccination scenario among children in the low and middle income countries as the money used for meeting other basic need. Therefore, it will take some time in educating the people aware and thereby improvising the need for vaccination for children among the low and middle-income countries.
Figure: PICOT Table
Source: By Author
Summarization of Key Criteria for Assessing the Risk of Bias
The important criteria used for accessing the risk of bias for evaluating the efficiency of intervention strategies for boosting and sustaining greater childhood vaccination in the low and middle-income countries are:
The Randomized controlled trials (RCT) that involved randomization either at the cluster level or at the individual level. However, for cluster RCTs, those who had a minimum of two control clusters and two interventions considered.
The Non-randomized control trials that had allocation at either the cluster level or the individual level. The studies that allowed allocation by alternation between groups using random methods or by changing birth dates or weekdays considered. However, for cluster trials only those with only two control clusters and interventions were included. In this context the two interventions and control clusters means intervention that reduces missed opportunities of vaccination for children. This may include supportive supervision, provider reminders, audit, and feedback. The other is the refresher courses, health education and training for the providers
Interventions of Health System that includes Interventions that lead to improvement of the quality of services such as stock management and transport for vaccine and provision for a cold chain system that is reliable. These also include intervention through outreach program of immunization in school and villages, expanding the time of service for immunization, increase in the budget for vaccinating, integration of the services of immunization with services of other healthcare practices and improvising plans of action for immunization coverage that leads to lesser diseases (Oyo-Ita 2016)
There is also Multi faceted immunization that involves combination of any of the above categories of intervention and other intervention targeted at improving the immunization coverage.
Summarizing the Main Findings of the Review
There are ten cluster RCT and four controlled trials randomized individually for meeting the criteria for inclusion. The countries in which the study was conducted the low and middle-income countries like India, Mexico, Nepal, Honduras, Georgia, Ghana, Pakistan, Zimbabwe and Nicaragua. This study evaluated interventions based on heath education based on community and facility, monetary incentives for households, visits to home and integration of the vaccination service for prevention of Malaria. The interventions included were either multifaceted or single. Moderate certainty evidence found for cases that involved sharing of information about the importance of vaccination for improving immunization coverage for children. There were also evidence of low certainty for improving the immunization scenario through specially designed reminder cards and integrating the immunization services with other healthcare services that dealt with prevention of malaria. There was evidence of low certainty when parents belonging to the low and middle-income countries provided monetary aid for ensuring that their children received the full doses of the required vaccine.
The interventions types identified in review include recipient oriented interventions, interventions that are provider oriented, health-system oriented interventions and interventions that are multifaceted. The recipient oriented intervention includes health education dealing with the completion of vaccination schedule, implementing immunization cards, pictorial presentation representing the importance of vaccine in saving lives of children and monetary incentives. The provider-oriented interventions involve providing training to the district managers and health providers on the right amount of vaccination doses. The interventions of the health-system oriented type includes visits to home for identification of non immunized children, ensuring outreach sessions for vaccination and integration of immunization with treatment of malaria. The multifaceted interventions include a combination of both health system and provider-oriented intervention.
Implications for Future Research
Regardless of the fact that vast amount of resources being dedicated for improving the exposure of immunization in the middle and low income countries, the findings however indicate moderate or low certainty. This rule out the any firm decision made on improvement of the vaccination scenario of the children. In this context, one can say that the certainty of any evidence ensures that any implemented intervention will lead to substantial change in the system. Thus, extensive study is required for the further evaluation more adaptable recall intervention and participant reminder in the low and middle-income countries as this is a successful way out in countries that represent higher income. Encouraging strategies for health education through communities through mass campaigning compared to health education based on facilities, as they are more effective. There should be multi-faceted and provider oriented interventions for bringing in a change in the immunization scenario of the low and middle-income countries. Imposing regulation on school entry based on vaccination for increasing its coverage. There making incentive facility for people who provide the vaccination. Implementation of plans for vaccination coverage for children and thereby reduce disease attacks. This may include sustainability measures for integrating routine vaccination services, impact of interventions on a long-term basis and identification of disease targeted. The plans should also include cost effectiveness resources, vaccination and interventions. Thus, these studies should mainly focus on factors that will ensure up taking vaccination for children in these countries.
There have been various agreements and disagreements of the review with various other studies. Previous systematic reviews on interventions for improvement in childhood vaccination faced difficulty in merging in a Meta analyses. The last research conducted on improving the immunization for children in the middle and low-income countries showed that in most of the studies that the promotion taken up community health workers for up taking immunization increases the number of children receiving the required vaccine. This particular study also stressed on importance of community based education on health and visits to home that were similar to other reviews for improving the immunization scenario. However, there were also findings that indicated that face-to-face information about the importance of immunization and alignment of immunization service with other services does not necessarily imply that it will lead to an improvement in the present scenario persisting in these countries. Thus, compared to other reviews this acts a gap in trying to improvise actions that will improve the scenario. Then the review also tries to find whether providing financial aid to the parents of these low and middle-income countries (LMICs) can actually ensure bringing in change to the existing scenario. This also provides gap in the theory as the evidence not supported by facts.
Oyo-Ita A, Wiysonge CS, Oringanje C, Nwachukwu CE, Oduwole O, Meremikwu MM. Interventions for improving coverage of childhood immunisation in low- and middle-income countries. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.:CD008145. DOI:10.1002/14651858.CD008145.pub3.At: