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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.