Interventions To Improve Vaccination Coverage of Children in Hard-To-Reach Population: A Systematic Review
Interventions To Improve Vaccination Coverage of Children in Hard-To-Reach Population: A Systematic Review
Interventions To Improve Vaccination Coverage of Children in Hard-To-Reach Population: A Systematic Review
Corresponding Author:
Samsriyaningsih Handayani
Faculty of Medicine
Universitas Airlangga
Fakultas Kedokteran, Kampus A, Jl. Mayjen Prof. Dr. Moestopo 47, Surabaya, 60131, Indonesia
Email: [email protected]
1. INTRODUCTION
The global vaccine action plan (GVAP) central vision is a world free from vaccine-preventable
diseases [1]. Since 2010, immunization has contributed significantly to reducing a quarter of the number of
child deaths due to vaccine-preventable disease worldwide, from 52 to 39 deaths per 1,000 live births
[2]. Vaccinations prevented 10 million deaths between 2010 and 2015, and many more since 2000 [3].
Vaccination coverage has also reportedly increased. The second dose of measles-containing-vaccine (MCV)
coverage increased from 42% in 2010 to 69% in 2018. There are 95 countries with DPT3 coverage of 90% in
each region, exceeding the GVAP target of 80% in every district [4]. However, there still are disparities. In
some regions with conflicts and weak health systems, remote areas, or urban slums, childhood vaccination
coverage remains low [5].
Low vaccination coverage levels prevent herd immunity to build, hence vulnerable to an outbreak.
Two doses of the measles vaccine with a minimum coverage of 97% are required to obtain herd immunity
against the measles virus in Europe [6]. Although national coverage of measles vaccine over World Health
Organization (WHO) standards, if the clustering of non-vaccination children exists, outbreaks can occur
because of the decreasing local immunity threshold [7], [8]. There are several causes for the low coverage of
immunization: marginalized economic and social status, poor urban areas, remote and rural areas [2]. This
condition is related to access and reachability. Hard-to-reach populations for vaccination are groups of people
who experience vaccination barriers due to distance and geographic location, non-permanent residence,
unavailability of health services, inadequate immunization systems, conflict, and war [9]. In Middle East,
conflict-stricken populations are low in vaccination coverage and treatable disease, resulting in cholera and
polio outbreaks [10]. Not only vaccination problems but also maternal health such as birth preparedness and
readiness level are also lower in hard-to-reach areas [11]. All this evidence suggests that addressing hard-to-
reach populations as a target intervention to improve maternal and child health, especially immunization, is
crucial in achieving 14 of the 17 sustainable development goals [12].
Special efforts are needed to conduct vaccination in hard-to-reach and areas. This kind of
intervention is usually high-cost [13], with non-vaccine cost (program management, human resources, social
mobilization, surveillance, capacity building) was higher than vaccine cost [14]. However, the finding from a
previous modeling study in Kenya showed that unvaccinated children with measles vaccine from 2016 to
2020 resulted in a loss of $9.5 million in medical costs and productivity, and conducting vaccination in
geography hard-to-reach area are highly cost-effective [15]. A modeled vaccination strategy in the
Democratic Republic of Congo also showed that delivering a second dose of MCV would save more than the
US $199 million [16]. This figure also indicates the importance of increasing vaccination coverage in hard-
to-reach populations.
A systematic review on delivering prevention of infectious disease in women and children in
conflict hard-to-reach settings had been conducted previously [17], but not evaluating the coverage increased
of interventions implemented. There has been no systematic review of which strategies effectively increase
childhood immunization coverage in hard-to-reach populations. Therefore, this systematic review was
prepared to evaluate interventions to increase child vaccination coverage in hard-to-reach populations.
2. RESEARCH METHOD
We conducted a systematic review of interventions to increase child vaccination coverage in hard-
to-reach populations. We used the PRISMA checklist as a writing guideline to ensure all steps are carried out
correctly [18]. Two reviewers were responsible for reviewing titles, abstracts, and full texts for inclusions.
Population, intervention, comparison, outcome (PICO) framework was used to clarify the eligibility criteria
for inclusion and exclusion of relevant articles [19], summarized in Table 1.
We only included studies in English. Study designs included as inclusion criteria were trials,
observational analytic studies, and before-after studies. Other exclusion criteria were studies with the pure
qualitative design, modeling, review, editorial, opinion, and commentary. Inaccessible studies were also an
exclusion criterion. To minimize the risk of bias, gray literature and studies that have not been peer-reviewed
were not included.
In conducting our search, we used a combination of five sets of keywords: i) Child, infant,
pediatrics; ii) hard-to-reach communities, hard-to-reach population, hard-to-reach area, remote area, difficult
area; ii) vaccination, immunization; iv) uptake, coverage, rates, outcomes; v) strategies, programs, interventions.
The search was conducted on four journal databases, Pubmed MEDLINE, SCOPUS, Web of
Science, and Science Direct. We searched for all studies published since 2012, one year after the initiation of
GVAP, hoping that the selected studies will reflect the follow-up of the launch of GVAP in 2011. All articles
obtained from the database search were imported into the Zotero database manager to identify duplicate
journals, review titles, and abstracts. Data extraction was carried out on selected articles for full-text review
by two reviewers independently. We use Microsoft Excel to tabulate extracted data. We included authors,
year of publication, study purpose, setting, design, subjects/ participants, interventions, outcomes, and
limitations of the study.
To minimize the risk of bias, we used several tools to assess risk of bias specific to each study
design. We used ROBINS-I for non-randomized studies for interventions [20] and RoB 2 for randomized
trials [21], with additional considerations for cluster-randomized trials [22]. For uniformity in judging the
overall risk of bias, we classified serious and critical risk of bias in ROBINS-I and high risk of bias in RoB 2
as "high risk". Otherwise, we categorized it as "low risk". In the event of disagreement, we resolved any
discrepancy by discussion and consensus. In this systematic review, each study's level of evidence was
assessed using the National Health and Medical Research Council (NHMRC) criteria [23].
The five included studies came from four different countries: Bangladesh (n=2), Afghanistan (n=1),
Pakistan (n=1), and India (n=1). Two articles had a cluster-randomized trial design, two quasi-experimental,
and one cross-sectional before-after study. The intervention duration varied with a minimum of 12 months
and a maximum of four years as shown in Table 2.
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Three studies evaluated single interventions, i.e., service innovation using mHealth application [24],
[28], and mobile outreach services under challenging locations [25]. Two other studies evaluated multiple
interventions consisting of refresher training, modification immunization schedule, community engagement,
immunization screening checklist [26], and community outreach to provide maternal and child health service
[27]. Four of the five studies reported a positive impact in increasing vaccination coverage [24]-[27], and one
study did not show superiority over than standard package [28]. Interventions that show good effectiveness in
increasing the coverage of childhood immunizations are the application of mHealth, given to vaccinators
with SMS reminders (OR 3.6, 95% CI 1.5 to 8.9, p<0.001). Multiple interventions involving the community,
modification of immunization schedules during outreach activities, and immunization screening cards also
effectively increased coverage (OR 3.02, 95% CI 2.58 to 3.54, p<0.01). Only one study using multiple
interventions reached the WHO target for immunization coverage >80% [26]. Changes in vaccination
coverage after intervention can be seen in Table 3 (see in appendix).
Four of five studies had a low to moderate risk of bias due to randomization. One study had critical
risk because it was not randomized, and no clear baseline for each group [25]. Deviations from intended
interventions were observed in two studies [24], [26], which reported no standardized interventions delivered
because of the context of intervention. All five studies had some concerns in measuring the outcome;
caregiver recall was used to obtain vaccination status. Although this method had quality concerns [29], this
method was still acceptable, especially in lower and middle-income countries, and encouraged to be used in
combination with vaccination cards and health care facilities documentation [30]. Due to the design of quasi-
experimental, repeated cross-sectional studies, there was unclear evidence of missing outcome data in three
studies [24]-[26]. Based on our pre-existing criteria assessment, four studies were categorized as low [24],
[26]-[28], and one study categorized as high risk of bias [25].
3.2. Discussion
This systematic review aimed to identify appropriate interventions to increase child vaccination
coverage in hard-to-reach populations. The five selected studies provided an overview of potential interventions
to increase child vaccination coverage in hard-to-reach populations. The limited number of studies that raised
this issue showed that child immunization in hard-to-reach populations had not been given much attention, even
though child vaccination coverage is still one of the world's global health problems [31].
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coverage than ImTeCHO. In India, ImTeCHO application was no superior to standard immunization
services. A previous study identified gaps in the performance of ASHAs in mobilizing mothers and children
for immunization [36]. However, giving mobile phones to ASHAs did not answer this problem. This
inconsistent benefit was also reported in a previous systematic review conducted by Cock et al. [37]
Furthermore, Oliver-Williams et al. [38] reported that only a little evidence supports mobile apps' use to
increase vaccination coverage. Therefore, despite 4.5 billion people have mobile phones and SMS technology
has proven to improve maternal and child health services in developing countries [39], the use of mobile apps
to increase vaccination coverage in hard-to-reach populations still needs further research.
Travel to health services affects infant vaccination coverage. Penta3 vaccination coverage was lower in
children who live with travel time to health services >60 minutes than <30 minutes [40]. In this case, mobile
health teams effectively reduced travel time to health care centers. A mobile clinic was a unit that aims to
provide medical services, diagnosis, and treatment for patients in remote areas [41]. Although common
obstacles to this type of intervention are financial problems, human resources, and logistical limitations [42],
this service is considered cost-effective compared to build a permanent health unit in remote and hard-to-reach
areas [41]. Therefore, to have sustainability in implementing this type of service, good planning of various
programs and funding must be done simultaneously by stakeholders.
A good schedule of team visits also enhanced mobile health teams' effectiveness. Studies in Nigeria
showed that immunization utilization was affected by health care problems. Lack of services, lack of health
personnel, and vaccines' absence on a predetermined schedule lead to low immunization utilization [43].
Modifications to the immunization schedule such as those carried out in Bangladesh were a strategic way of
dealing with this. Changing the outreach schedule by mobile immunization from one day monthly to every
two months for two days provides more opportunities for every child to access immunizations. More children
can be served by staying longer because the vaccination service is not limited to particular hours. Parents
who work in the morning can bring their child in the afternoon or the following day. For officers, this
schedule modification also saves expenses because they do not need to come every month. This schedule
change is also in accordance with the WHO routine immunization schedule recommendations, which allows
intervals between DPT vaccines of four and eight weeks [44].
One of the things that are very crucial in immunization services besides coverage is the quality of
vaccines. The most potential of the vaccine can be achieved if the cold chain system is well implemented. This
includes vaccine storage and transportation from factories to health facilities where vaccinations are carried out
and outreach locations. Various methods were developed to improve the vaccine delivery system, namely
preventing vaccine freezing using cold water instead of ice, temperature monitoring systems in vials, and better
cold chain related control and regulatory systems [45]. One of the efforts made to maintain the cold chain
system's integrity in hard-to-reach areas is re-designing the vaccine delivery system, as reported by Uddin et al.
in Bangladesh. Vaccines were no longer sent from an area's capital but rather sent from adjacent cities [26]. The
goal was to cut the mileage and reduce travel time to reduce vaccine damage due to the long trip. This method is
good enough but requires more coordination with other districts as it will also change their cold chain system.
This needed additional work by officials from other districts to get the vaccine to a certain point, which requires
additional costs and therefore should be included in the evaluation component.
In Bangladesh, the establishment of a community support group consisting of immunization hosts,
mothers with fully immunized children, village defense members, male and female students, representatives
of non-profit organizations, traditional birth attendants, and traditional healers increased vaccination
coverage [26]. A study from Pakistan also reported increased vaccination coverage after training lady health
workers and traditional birth attendants as community mobilizers [46]. Habib et al. reported that community
communication campaigns have also effectively increased oral polio immunization coverage [27]. However,
this kind of intervention is usually hindered by funding constraints, inadequate infrastructure and equipment,
community stakeholders' attitudes, and political factors [47].
Uddin et al. reported positive outcomes from multiple interventions to improve the health system
[26]. Refresher training for Public Health staff, re-design vaccine supply system, and providing immunization
screening checklist increased complete immunization coverage 26 to 29%. The combination of this
intervention with community engagement increased the coverage even more remarkable, with OR 3.02,
compared to baseline. These interventions were worldwide accepted and recommended to improve
vaccination coverage. Refresher training has been routinely recommended to strengthen the immunization
program. It is recommended by WHO [48], and UNICEF recommended rapid card check for immunization
to evaluate immunization program at the household level [49]. Thus, the combination of these interventions
was worked better.
3.2.4. Limitations
This systematic review's major limitation was the small number of studies identified. Differences in
design between studies make it difficult to conclude the size of the impact of more controlled interventions.
There were only two randomized controlled trial (RCT) studies with a low risk of bias, two quasi-
experimental studies with a low risk of bias, and one cross-sectional study with a high risk of bias in this
systematic review. Therefore, conclusions regarding the intervention's effectiveness are varying. Considering
all these limitations, the level of evidence for interventions to increase vaccination coverage for children in
hard-to-reach populations is therefore low (NHMRC level of evidence III-3).
4. CONCLUSION
To our knowledge, this is the first article that systematically reviewed interventions to improve
vaccination coverage in hard-to-reach populations. Our systematic review shows that the mHealth application
shows high effectiveness if appropriately addressed, although it needs further research. Multiple interventions
involving existing health systems are highly effective and low-cost. Mobilization of health teams to hard-to-
reach areas can increase vaccination coverage but requires high costs and additional resources to carry out
these activities. Costs can be reduced if the intervention is integrated with the existing health system so that
there is no need to bring in additional human resources. However, we recommend that additional incentives
be provided to health workers and community groups who conduct outreach to motivate them to carry out
their duties. Given the costs incurred, better program planning and targeting a broader program are needed to
increase the effectiveness of the already incurred costs.
ACKNOWLEDGEMENTS
The authors would like to thank Universitas Airlangga library for providing access to journal
databases.
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Int. J. Public Health Sci., Vol. 10, No. 3, September 2021 : 646 – 656