Realist Synthesis of the International Theory and Evidence on Strategies to Improve Childhood Vaccination in Low- and Middle-Income Countries: Developing Strategies for the Nigerian Healthcare System

Document Type : Review Article

Authors

Health Services Management Centre, University of Birmingham, Birmingham, UK

Abstract

Background
Childhood vaccination coverage rates in low- and middle-income countries (LMICs) vary significantly, with some countries achieving higher rates than others. Several attempts have been made in Nigeria to achieve universal vaccination coverage but with limited success. This study aimed to analyse strategies used to improve childhood vaccine access and uptake in LMICs in order to inform strategy development for the Nigerian healthcare system.

 
Methods
A realist synthesis approach was adopted in order to elucidate the contexts and mechanisms wherewith these strategies achieved their aim (or not). Nine databases were searched for relevant articles and 27 articles were included in the study. Programme theories were generated from the included articles, and data extraction was carried out paying particular attention to context, mechanism and outcomes configurations.

 
Results
Interventions used in LMICs to improve vaccination coverage were categorised as follows: communication/ educational, reminder-type, incentives, social mobilisation, provider-directed strategies, health service integration and multi-pronged strategies. The strategies that appeared most likely to be effective in the health contexts of contemporary Nigeria include communication and educational interventions; employing informal change agents, and; monitoring and evaluation to strengthen communication. The programme theories for the use of reminders, social mobilisation, staff training and supportive supervision were observed in practice, and these strategies were generally successful within some contexts. By contrast, the use of monetary incentives in Nigeria is not supported by the evidence, although further research and evaluation is required. The integration of other interventions with routine immunisation (RI) to improve uptake was more effective when the perceived value of the other program was high. Adoption of multipronged interventions for hard to reach communities was beneficial. However, caution should be exercised because of varying levels of published evidence in respect of each intervention type and a relative lack of the rich description required to conduct a full realist analysis.

 
Conclusion
This paper adds to the evidence base on the adaption of strategies to improve vaccine access and uptake to the context of LMICs.

Highlights

 

Supplementary File 1 (Download)

 

Keywords

Main Subjects


  1. Centers for Disease Control and Prevention (CDC). (2018) What are the Reasons to Vaccinate My Baby? Available at: https://www.cdc.gov/features/reasonstovaccinate/index.html.   Accessed September 8, 2019. Published 2018.
  2. World Health Organization (WHO). The Addis Declaration on Immunization. https://www.afro.who.int/health-topics/immunization/the-addis-declaration-immunization.  Accessed September 9, 2019. Published 2017.
  3. World Health Organization (WHO). Business case for WHO immunization activities on the African continent, 2018–2030. https://apps.who.int/iris/bitstream/handle/10665/272537/9789290234111-eng.pdf. Accessed September 9, 2019. Published 2018.
  4. World Health Organization (WHO). Immunization Coverage. https://www.who.int/news-room/fact-sheets/detail/immunization-coverage. Accessed September 9, 2019. Published 2019.
  5. World Bank. Databank World Development Indicators. https://databank.worldbank.org/source/world-development-indicators#.  Accessed September 8, 2019. Published 2019.
  6. FMOH (2015) Comprehensive EPI Multi-Year Plan 2016 – 2020 National Primary Health Care Development Agency (in collaboration with Immunization Partners). http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/nigeria/nigeria_cmyp_2016-2020.pdf.   Accessed September 9, 2019.
  7. National Primary Health Care Development Agency (NPHCDA). 2018 Nigeria Polio Eradication Emergency Plan. Nigeria: NPHCDA; 2018.
  8. National Primary Health Care Development Agency (NPHCDA). Comprehensive EPI Multi-Year Plan 2011-2015 updated. Nigeria: NPHCDA; 2011.
  9. National Primary Health Care Development Agency (NPHCDA). National Routine Immunization Strategic Plan 2013-2015: Intensifying Reaching Every Ward through Accountability. Nigeria: NPHCDA; 2013.
  10. FMOH (2018) Nigeria Strategy for Immunisation and PHC System Strengthening [NSIPSS] 2018 – 2028 National Primary Health Care Development Agency (In collaboration with other stakeholders).
  11. World Bank. World Bank Country and Lending Groups. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.   Accessed March 13, 2019. Published 2019.
  12. ORWA Department (2013) Country Strategy Paper 2013-2017. Nigeria: Africa Development Bank Group. http://www.afdb.org/fileadmin/uploads/afdb/Documents/Project-and-Operations/Nigeria%20-%202013-2017%20-%20Country%20Strategy%20Paper.pdf.   Accessed August 1, 2016.
  13. Antai D. Inequitable childhood immunization uptake in Nigeria: a multilevel analysis of individual and contextual determinants. BMC Infect Dis. 2009;9:181. doi:10.1186/1471-2334-9-181
  14. Gray A, Miller R. The Provision of Public Goods and Services by Socially Oriented Entrepreneurs: Experiences of Indian Healthcare. In: Guerrero P, Wilkins P, eds. Doing Public Good? Private Actors, Evaluation and Public Value. New Brunswick: Transaction Publishers; 2015.
  15. Pawson R. Evidence-Based Policy: A Realist Perspective. London: Sage publications; 2006.
  16. Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: realist syntheses. BMC Med. 2013;11:21. doi:10.1186/1741-7015-11-21
  17. Pettigrew A, Ferlie E, McKee L. Shaping strategic change ‐ the case of the NHS in the 1980s. Public Money & Management. 1992;12(3):27-31. doi:10.1080/09540969209387719
  18. Oyo-Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low- and middle-income countries. Cochrane Database Syst Rev. 2011(7):Cd008145. doi:10.1002/14651858.CD008145.pub2
  19. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review--a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005;10 Suppl 1:21-34. doi:10.1258/1355819054308530
  20. Pawson R, Tilley N. Realistic evaluation. London: Sage Publications; 1997.
  21. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):W65-94. doi:10.7326/0003-4819-151-4-200908180-00136
  22. Pearson M, Hunt H, Cooper C, Shepperd S, Pawson R, Anderson R. Intermediate care: a realist review and conceptual framework. Final report. NIHR Service Delivery and Organisation Programme; 2013.
  23. Andersson N, Cockcroft A, Ansari NM, et al. Evidence-based discussion increases childhood vaccination uptake: a randomised cluster controlled trial of knowledge translation in Pakistan. BMC Int Health Hum Rights. 2009;9 Suppl 1:S8. doi:10.1186/1472-698x-9-s1-s8
  24. Bolam A, Manandhar DS, Shrestha P, Ellis M, Costello AM. The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled trial. BMJ. 1998;316(7134):805-811. doi:10.1136/bmj.316.7134.805
  25. Oku A, Oyo-Ita A, Glenton C, et al. Communication strategies to promote the uptake of childhood vaccination in Nigeria: a systematic map. Glob Health Action. 2016;9:30337. doi:10.3402/gha.v9.30337
  26. Owais A, Hanif B, Siddiqui AR, Agha A, Zaidi AK. Does improving maternal knowledge of vaccines impact infant immunization rates? a community-based randomized-controlled trial in Karachi, Pakistan. BMC Public Health. 2011;11:239. doi:10.1186/1471-2458-11-239
  27. Pandey P, Sehgal AR, Riboud M, Levine D, Goyal M. Informing resource-poor populations and the delivery of entitled health and social services in rural India: a cluster randomized controlled trial. Jama. 2007;298(16):1867-1875. doi:10.1001/jama.298.16.1867
  28. Abdul Rahman MA, Al-Dabbagh SA, Al-Habeeb QS. Health education and peer leaders' role in improving low vaccination coverage in Akre district, Kurdistan Region, Iraq. East Mediterr Health J. 2013;19(2):125-129.
  29. Usman HR, Akhtar S, Habib F, Jehan I. Redesigned immunization card and center-based education to reduce childhood immunization dropouts in urban Pakistan: a randomized controlled trial. Vaccine. 2009;27(3):467-472. doi:10.1016/j.vaccine.2008.10.048
  30. Usman HR, Rahbar MH, Kristensen S, et al. Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization card and maternal education. Trop Med Int Health. 2011;16(3):334-342. doi:10.1111/j.1365-3156.2010.02698.x
  31. Waisbord S, Shimp L, Ogden EW, Morry C. Communication for polio eradication: improving the quality of communication programming through real-time monitoring and evaluation. J Health Commun. 2010;15 Suppl 1:9-24. doi:10.1080/10810731003695375
  32. Banerjee AV, Duflo E, Glennerster R, Kothari D. Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives. BMJ. 2010;340:c2220. doi:10.1136/bmj.c2220
  33. Barham T, Maluccio JA. Eradicating diseases: the effect of conditional cash transfers on vaccination coverage in rural Nicaragua. J Health Econ. 2009;28(3):611-621. doi:10.1016/j.jhealeco.2008.12.010
  34. Maluccio J, Flores R. Impact evaluation of a conditional cash transfer program: The Nicaraguan Red de Protección Social. Washington DC: International Food Policy Research Institute; 2004.
  35. Morris SS, Flores R, Olinto P, Medina JM. Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial. Lancet. 2004;364(9450):2030-2037. doi:10.1016/s0140-6736(04)17515-6
  36. Robertson L, Mushati P, Eaton JW, et al. Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial. Lancet. 2013;381(9874):1283-1292. doi:10.1016/s0140-6736(12)62168-0
  37. Bangure D, Chirundu D, Gombe N, et al. Effectiveness of short message services reminder on childhood immunization programme in Kadoma, Zimbabwe - a randomized controlled trial, 2013. BMC Public Health. 2015;15:137. doi:10.1186/s12889-015-1470-6
  38. Domek GJ, Contreras-Roldan IL, O'Leary ST, et al. SMS text message reminders to improve infant vaccination coverage in Guatemala: a pilot randomized controlled trial. Vaccine. 2016;34(21):2437-2443. doi:10.1016/j.vaccine.2016.03.065
  39. Brugha RF, Kevany JP. Maximizing immunization coverage through home visits: a controlled trial in an urban area of Ghana. Bull World Health Organ. 1996;74(5):517-524.
  40. Weiss WM, Rahman MH, Solomon R, Singh V, Ward D. Outcomes of polio eradication activities in Uttar Pradesh, India: the Social Mobilization Network (SM Net) and Core Group Polio Project (CGPP). BMC Infect Dis. 2011;11:117. doi:10.1186/1471-2334-11-117
  41. Djibuti M, Gotsadze G, Zoidze A, Mataradze G, Esmail LC, Kohler JC. The role of supportive supervision on immunization program outcome - a randomized field trial from Georgia. BMC Int Health Hum Rights. 2009;9 Suppl 1:S11. doi:10.1186/1472-698x-9-s1-s11
  42. Uskun E, Uskun SB, Uysalgenc M, Yagiz M. Effectiveness of a training intervention on immunization to increase knowledge of primary healthcare workers and vaccination coverage rates. Public Health. 2008;122(9):949-958. doi:10.1016/j.puhe.2007.10.005
  43. Briere EC, Ryman TK, Cartwright E, et al. Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers. J Infect Dis. 2012;205 Suppl 1:S56-64. doi:10.1093/infdis/jir779
  44. Dicko A, Toure SO, Traore M, et al. Increase in EPI vaccines coverage after implementation of intermittent preventive treatment of malaria in infant with Sulfadoxine -pyrimethamine in the district of Kolokani, Mali: results from a cluster randomized control trial. BMC Public Health. 2011;11:573. doi:10.1186/1471-2458-11-573
  45. Mathanga DP, Luman ET, Campbell CH, Silwimba C, Malenga G. Integration of insecticide-treated net distribution into routine immunization services in Malawi: a pilot study. Trop Med Int Health. 2009;14(7):792-801. doi:10.1111/j.1365-3156.2009.02295.x
  46. Ryman TK, Briere EC, Cartwright E, et al. Integration of routine vaccination and hygiene interventions: a comparison of 2 strategies in Kenya. J Infect Dis. 2012;205 Suppl 1:S65-76. doi:10.1093/infdis/jir777
  47. Hayford K, Uddin MJ, Koehlmoos TP, Bishai DM. Cost and sustainability of a successful package of interventions to improve vaccination coverage for children in urban slums of Bangladesh. Vaccine. 2014;32(20):2294-2299. doi:10.1016/j.vaccine.2014.02.075
  48. Hu Y, Luo S, Tang X, et al. Does introducing an immunization package of services for migrant children improve the coverage, service quality and understanding? an evidence from an intervention study among 1548 migrant children in eastern China. BMC Public Health. 2015;15:664. doi:10.1186/s12889-015-1998-5
  49. Uddin MJ, Larson CP, Oliveras E, Khan AI, Quaiyum MA, Saha NC. Child immunization coverage in urban slums of Bangladesh: impact of an intervention package. Health Policy Plan. 2010;25(1):50-60. doi:10.1093/heapol/czp041
  50. Uddin MJ, Saha NC, Islam Z, et al. Improving low coverage of child immunization in rural hard-to-reach areas of Bangladesh: findings from a project using multiple interventions. Vaccine. 2012;30(2):168-179. doi:10.1016/j.vaccine.2011.11.030
  51. Sidani S, Sechrest L. Putting program theory into operation. Am J Eval. 1999;20(2):227-238. doi:10.1177/109821409902000205
  52. Sharpe G. A review of program theory and theory-based evaluations. Am Int J Contemp Res. 2011;1(3):72-75.
  53. Lewin S, Hill S, Abdullahi LH, et al. 'Communicate to vaccinate' (COMMVAC). building evidence for improving communication about childhood vaccinations in low- and middle-income countries: protocol for a programme of research. Implement Sci. 2011;6:125. doi:10.1186/1748-5908-6-125
Volume 9, Issue 7
July 2020
Pages 274-285
  • Receive Date: 03 April 2019
  • Revise Date: 23 September 2019
  • Accept Date: 12 November 2019
  • First Publish Date: 01 July 2020