Mathew, in a mammoth exercise, has looked at a large number of reports
examining the coverage of routine vaccinations (RI) in various settings
evaluating multiple factors to assess disparities in RI in different
populations groups in India [1]. Criteria such as urban and rural
communities, parental economic status, number of siblings etc have been
evaluated using diverse methodology. The conclusions listed in the box
bring out what is well known. Parents who are not informed of the
benefits of protective immunizations do not undertake the "trouble" to
get the child vaccinated or drop out without completion of the
recommended doses. Similarly basic health care services, which are
provided free of cost, often remain unutilized.
A recent randomized controlled study [2] carried out
in low income sites in Karachi, Pakistan, including urban and peri-urban
communities, examined if improving maternal knowledge of vaccination had
an impact on infant immunization rates. The intervention consisted of
conveying three key messages to the family explaining (i) how
vaccines saved children’s lives, (ii) logistic information about
vaccination centers, and (iii) significance of retaining
immunization cards. These were communicated using easy-to-understand
pictorial cards by trained child health workers (CHWs). The control
group received general health promotional messages also given by CHWs.
The intervention group showed an improvement in RI coverage by 39%. The
authors concluded that providing vaccine related targeted education to
mothers at home was an effective and practical strategy to improve
childhood immunization rates in low literacy settings. This unique study
is particularly relevant to conditions in India, which has very poor RI
coverage in many states.
Efforts to increase RI coverage have mostly addressed
delivery and provider factors (subject of numerous investigations).
However, it is crucial to provide functional health literacy (ability to
read and understand basic health related information) for the family and
the community at large, thus creating a demand. Modification of
health-seeking behaviour is more successful if the messages are clearly
understood. There are lessons to be learnt from the polio eradication
campaign in India, which required massive "community mobilization"
during the later phase, whereas countries like Bangladesh and Srilanka
with very high RI coverage were polio free by the year 2000. RI must
become a routine practice and a component of normal care of the growing
child. Issues of equity become irrelevant in that setting.
1. Mathew JL. Inequity in childhood immunization in
India: a systematic review. Indian Pediatr. 2012;49:203-23.
2. Owais A, Hanif B, Siddiqui A, 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;11:239-47.