Beyond constructs and principles: addressing gender-related barriers to high, equitable immunization coverage.

The global immunization community has only recently recognized that addressing gender-related barriers to vaccination is critical to improving equity and increasing protection against vaccine-preventable diseases. USAID's MOMENTUM Routine Immunization Transformation and Equity project aims to strengthen routine immunization programs to overcome entrenched obstacles to reaching zero-dose and under-immunized children while supporting the introduction of other new vaccines given over the life course. From the outset, the project recognized the need to mainstream gender into its global and country level work, incorporating gender considerations into all phases of the program cycle, from assessment to activity design, strategic communications, monitoring, evaluation, and continuous learning. Its gender mainstreaming efforts focus on five areas of improvement for immunization: service access and convenience; service quality and experience; communication and demand generation for immunization among caregivers (both women and men) and families; making services more responsive to agency and autonomy constraints of female caregivers; and the conditions and circumstances of health workers, who are mostly women. The authors describe approaches the project has applied to build capacity of its own global and country level staff to both recognize the gender dimensions inherent in common obstacles to immunization and ways to address them. Authors describe project activities carried out at global and country levels and share experience and challenges encountered in increasing recognition of gender barriers, moving from theory to practical action in addressing them, building capacity, and gauging the success of the work to date. The lessons learned are useful to colleagues working within the circumstances of time-limited and geography-specific projects whose main focus is to improve equity in immunization.

Harnessing the Power of Collaboration to Expand the Coverage and Equity of COVID-19 Vaccinations in India: A Community Collaboration Model.

Early in 2021, India embarked on the uphill journey of the COVID-19 vaccination of the largest population group in the world in a prioritized manner and in the shortest possible time. Considering the endless variety of geography and diverse socio-economic demographic, religious, and community contexts, there was a high likelihood of certain population subgroups with known vulnerabilities facing inequities, which were anticipated to be further accentuated by a digital divide. This necessitated devising solutions for such communities in a localized manner to aid the local government in breaking the service access and uptake barriers with an inclusive approach. To bridge this vital gap, the Momentum Routine Immunization Transformation and Equity project implemented a three-tiered collaboration, viz., government, non-governmental organizations (NGOs), and a wide range of vulnerable and at-risk communities, utilizing knowledge exchange and use of data. The project implemented localization strategies through the NGOs for community engagement in conjunction with government vaccination teams to universalize COVID-19 vaccination uptake up to the last mile. The collaboration resulted in reaching close to 50 million beneficiaries through messaging and facilitated the administration of more than 14 million vaccine doses, including 6.1 million doses for vulnerable and marginalized communities in 18 States and Union territories in India, along with suggesting implications for public health practice and research.

Measuring National Immunization System Performance: A Systematic Assessment of Available Resources.

BACKGROUND: Vaccination coverage is widely used to assess immunization performance but, on its own, provides insufficient information to drive improvements. Assessing the performance of underlying components of immunization systems is less clear, with several monitoring and evaluation (M&E) resources available for use in different operational settings and for different purposes. We studied these resources to understand how immunization system performance is measured. METHODS: We reviewed peer-reviewed and gray literature published since 2000 to identify M&E resources that include national-level indicators measuring the performance of immunization systems or their components (governance, financing, regulation, information systems, vaccine logistics, workforce, service delivery, and demand generation). We summarize indicators by the system components or outcomes measured and describe findings narratively. RESULTS: We identified 20 resources to monitor immunization program objectives and guide national strategic decision-making, encompassing 631 distinct indicators. Indicators for immunization program outcomes comprised the majority (124/631 [19.7%]), largely vaccination coverage (110/124 [88.7%]). Almost all resources (19/20 [95%]) included indicators for vaccine logistics (83/631 [13.2%]), and those for regulation (19/631 [3.0%]) and demand generation (28/631 [4.4%]) were least common. There was heterogeneity in how information systems (92/563 [14.6%]) and workforce (47/631 [7.4%]) were assessed across resources. Indicators for vaccination coverage in adults, data use in decision-making, equity and diversity, effectiveness of safety surveillance, and availability of a public health workforce were notably lacking. CONCLUSIONS: Between the resources identified in this review, we identified considerable variability and gaps in indicators assessing the performance of some immunization system components. Given the multitude of indicators, policymakers may be better served by tailoring evaluation resources to their specific context to gain useful insight into health system performance and improve data use in decision-making for immunization programs.

Engaging Faith-Based Organizations for Promoting the Uptake of COVID-19 Vaccine in India: A Case Study of a Multi-Faith Society.

Mass vaccination, currently the most promising solution to contain communicable diseases, including COVID-19 requires collaboration between a variety of partners to improve the supply and demand and alleviate vaccine inequity. Vaccine hesitancy features in WHO's list of top 10 threats to global health, and there is plethora of disinformation instigating conflict between COVID-19 vaccination drive and religious sentiments. Negotiating public health partnerships with FBOs (Faith Based Organizations) has always been challenging. A handful of faith leaders have always shown resistance to ideas such as child immunization, and family planning. Many others have been supportive on other fronts like helping people with food, shelter, and medical aid in the times of public health crisis. Religion is an important part of life for the majority of the Indian population. People confide in faith-based leaders in the times of difficulty. This article presents experiences from the strategic engagement with FBOs (entities dedicated to specific religious identities, often including a social or moral component) to promote uptake of COVID-19 vaccination, especially among the vulnerable and marginalized communities. The project team collaborated with 18 FBOs and more than 400 religious institutions to promote COVID-19 vaccination and build confidence for the vaccination program. As a result, a sustainable network of sensitized FBOs from diverse faiths was created. The FBOs mobilized and facilitated vaccination of 0.41 million beneficiaries under the project.

Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria.

BACKGROUND: The importance of immunization for child survival underscores the need to eliminate immunization inequalities. Few existing studies of inequalities use approaches that view the challenges and potential solutions from the perspective of caregivers. This study aimed to identify barriers and context-appropriate solutions by engaging deeply with caregivers, community members, health workers, and other health system actors through participatory action research, intersectionality, and human-centered design lenses. METHODS: This study was conducted in the Demographic Republic of Congo, Mozambique and Nigeria. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. We analyzed the data using the UNICEF Journey to Health and Immunization Framework. RESULTS: Caregivers of zero-dose and under-immunized children faced multiple intersecting and interacting barriers related to gender, poverty, geographic access, and service experience. Immunization programs were not aligned with needs of the most vulnerable due to the sub-optimal implementation of pro-equity strategies, such as outreach vaccination. Caregivers and communities identified feasible solutions through co-creation workshops and this approach should be used whenever possible to inform local planning. CONCLUSIONS: Policymakers and managers can integrate HCD and intersectionality mindsets into existing planning and assessment processes, and focus on overcoming root causes of sub-optimal implementation.

Integration of other services with human papillomavirus vaccination; lessons from earlier in the life course highlight the need for new policy and implementation evidence.

Integration of vaccination against human papillomavirus (HPV) with other essential health services for adolescents has been proposed in global strategies and tested in demonstration projects in low- and middle-income countries (LMIC). Published experiences, global guidance, and one key example, the implementation of "HPV Plus" in Tanzania, all demonstrate the need for greater operational evidence to guide future implementation and policy. Review of experiences earlier in the life course, integrating post-partum family planning with infant immunization, show lessons from 13 LMICs that can apply to provision of adolescent health information and services alongside HPV vaccination. Three distinct models of integration emerge from this review comprising: 1) multiple tasks and functions by health staff providing vaccination and other care, or 2) secondary tasks added to the main function of vaccination, or 3) co-location of matched services provided by different staff. These models, with strengths and weaknesses demonstrated in family planning and immunization experiences, apply in different ways to the three main platforms used for HPV vaccination: school, facility or community. For HPV vaccination policy and programming, an initial need is to combine the existing evidence on vaccine service delivery - including coverage, efficiency, cost, and cost-effectiveness information - with what is known on how integration works in practice; the operational detail and models employed. This synthesis may enable assessment which models best suit the different service delivery platforms. An additional need is to link this with more tailored local assessments of the adolescent burden of disease and other determinants of their well-being to develop new thinking on what can and cannot be done to integrate other services alongside HPV vaccination. New approaches placing adolescents at the center are needed to design services tailored to their preferences and needs. The potential synergies with cervical cancer screening and treatment for older generations of women, also require further exploration. Coordinated action aligning HPV vaccination with broader adolescent health and wellbeing will generate social, economic and demographic benefits, which in themselves are sufficient justification to devote more attention to integrated approaches.

Operationalizing Integrated Immunization and Family Planning Services in Rural Liberia: Lessons Learned From Evaluating Service Quality and Utilization.

BACKGROUND: Integration of family planning and immunization services provides an opportunity to meet women's need for postpartum family planning and infants' vaccination needs through client-centered care, while reducing financial and opportunity costs for families. The United States Agency for International Development's Maternal and Child Survival Program (MCSP) supported the Liberia Ministry of Health to scale up integrated family planning and immunization services as part of a broader service delivery and health systems recovery program after the Ebola epidemic. METHODS: We conducted a mixed-methods program evaluation in 22 health facilities in Grand Bassa and Lofa counties. Family planning uptake and immunization dropout rates at project sites were compared to rates at 18 matched health facilities in the same counties. We conducted 34 focus group discussions with community members and 43 key informant interviews with health care providers and managers to explore quality of care and contextual factors affecting provision and use of integrated services including postpartum family planning. RESULTS: From November 2016 to July 2017, 1,066 women accepted referrals from immunization to family planning counseling (10% of all vaccinator-caregiver interactions); the majority of women who were referred (75%) accepted a family planning method the same day. Trends indicated slightly higher family planning uptake in intervention over nonintervention facilities, but differences were not statistically significant. Pentavalent vaccine dropout rates did not increase in intervention compared to nonintervention facilities indicating no negative impact on utilization of immunization services. Clients and providers expressed that the integrated services reduced costs and time for the clients, educated mothers about postpartum family planning, and ensured infants were completing their vaccinations. Providers expressed the need for increased human resources to meet the elevated demand for family planning counseling services and additional focus on community-level social and behavior change activities. Both groups emphasized that social stigma and norms about postpartum sexual abstinence prevented many women from seeking postpartum family planning services. CONCLUSION: Although scaling up integrated family planning-immunization services may be programmatically feasible and acceptable to clients and providers, the intervention's success and ability to understand and quantify impact are driven by the effect of contextual factors and fidelity to the intervention approach. Contextual factors need to be understood before implementation, measured during implementation, and addressed throughout implementation to maximize the approach's impact on service utilization and health outcomes.

Successful proof of concept of family planning and immunization integration in Liberia.

Globally, unmet need for postpartum family planning remains high, while immunization services are among the most wide-reaching and equitable interventions. Given overlapping time frames, integrating these services provides an opportunity to leverage existing health visits to offer women more comprehensive services. From March through November 2012, Liberia's government, with support from the Maternal and Child Health Integrated Program (MCHIP), piloted an integrated family planning and immunization model at 10 health facilities in Bong and Lofa counties. Vaccinators provided mothers bringing infants for routine immunization with targeted family planning and immunization messages and same-day referrals to co-located family planning services. In February 2013, we compared service statistics for family planning and immunization during the pilot against the previous year's statistics. We also conducted in-depth interviews with service providers and other personnel and focus group discussions with clients. Results showed that referral acceptance across the facilities varied from 10% to 45% per month, on average. Over 80% of referral acceptors completed the family planning visit that day, of whom over 90% accepted a contraceptive method that day. The total number of new contraceptive users at participating facilities increased by 73% in Bong and by 90% in Lofa. Women referred from immunization who accepted family planning that day accounted for 44% and 34% of total new contraceptive users in Bong and Lofa, respectively. In Lofa, pilot sites administered 35% more Penta 1 and 21% more Penta 3 doses during the pilot period compared with the same period of the previous year, while Penta 1 and Penta 3 administration decreased in non-pilot facilities. In Bong, there was little difference in the number of Penta 1 and Penta 3 doses administered between pilot and non-pilot facilities. In both counties, Penta 1 to Penta 3 dropout rates increased at pilot sites but not in non-pilot facilities, possibly due to higher than average background dropout rates at pilot sites prior to the intervention in Lofa and the disproportionate effect of data from 1 large facility in Bong. The project provided considerable basic support to assess this proof of concept. However, results suggest that introducing a simple model that is minimally disruptive to existing immunization service delivery can facilitate integration. The model is currently being scaled-up to other counties in Liberia, which could potentially contribute to increased postpartum contraceptive uptake, leading to longer birth intervals and improved health outcomes for children and mothers.

Drivers of routine immunization coverage improvement in Africa: findings from district-level case studies.

There is limited understanding of why routine immunization (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, we conducted in-depth case studies to understand pathways to coverage improvement by comparing immunization programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques we compared the experience of districts where diphtheria-tetanus-pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunization services and drivers of coverage improvement. The results informed a model for immunization coverage improvement that emphasizes the dynamics of immunization systems at district level. In all districts, whether improving or steady, we found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. We found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness. We identified six common drivers of RI coverage performance improvement-four direct drivers and two enabling drivers-that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasize the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunization system performance.

Moving forward with strengthening routine immunization delivery as part of measles and rubella elimination activities.

The Global Vaccine Action Plan includes a goal of meeting global and regional measles and rubella elimination targets, noting that such efforts should not operate in silos but be coordinated with other immunization efforts. Similarly, the Global Measles and Rubella Strategic Plan for 2012-2020 emphasizes the need for integrated approaches to achieve and maintain very high levels of population immunity using both routine immunization and supplemental immunization activities (SIAs). The strategic plan also includes routine vaccination coverage targets, highlighting the critical role of strong routine immunization systems as a cornerstone for sustainable measles control/elimination efforts. It encourages exploiting the resources and visibility of SIAs to strengthen routine immunization, thereby reducing the frequency with which SIAs are needed. Documented examples of doing so include training health workers, procuring cold chain equipment, and improving injection safety and adverse events management. However, the concept has been put into practice only to a limited extent and missed opportunities persist regarding this aspect of SIA planning and execution. This paper draws on recent studies of the interaction between measles activities and health systems as well as country experiences in using SIAs to strengthen routine immunization. It identifies obstacles and enabling factors to doing so and proposes options for systematically strengthening routine immunization as part of a best practice SIA.

Why children are not vaccinated: a review of the grey literature.

In collaboration with WHO, IMMUNIZATION basics analyzed 126 documents from the global grey literature to identify reasons why eligible children had incomplete or no vaccinations. The main reasons for under-vaccination were related to immunization services and to parental knowledge and attitudes. The most frequently cited factors were: access to services, health staff attitudes and practices, reliability of services, false contraindications, parents' practical knowledge of vaccination, fear of side effects, conflicting priorities and parental beliefs. Some family demographic characteristics were strong, but underlying, risk factors for under-vaccination. Studies must be well designed to capture a complete picture of the simultaneous causes of under-vaccination and to avoid biased results. Although the grey literature contains studies of varying quality, it includes many well-designed studies. Every immunization program should strive to provide quality services that are accessible, convenient, reliable, friendly, affordable and acceptable, and should solicit feedback from families and community leaders. Every program should monitor missed and under-vaccinated children and assess and address the causes. Although global reviews, such as this one, can play a useful role in identifying key questions for local study, local enquiry and follow-up remain essential.

Rapid assessment of injection practices in Mongolia.

BACKGROUND: Anecdotal reports suggest that unsafe injections may transmit blood-borne pathogens in Mongolia. METHODS: The Ministry of Health of Mongolia collected information on injection practices, their determinants, and their consequences through interviews and observations of a small convenience sample of prescribers, injection providers, and members of the general population. RESULTS: The 65 members of the general population reported receiving an average of 13 injections per year. New, single-use injection devices were used in the 20 health care facilities visited. There were breaks in infection control practices while administering injections, including observations of 500-mL intravenous infusion bottles used as multiple-dose diluent vials and 8 of the 28 providers (28%) reporting reuse of device on the same patient. Injection providers reported 2.6 needle-stick injuries per year. Contaminated sharps were burned in a drum. Among persons interviewed, 19 of the 21 prescribers (90%) and 49% of the population were aware of the potential risk of HIV transmission through unsafe injections. CONCLUSIONS: A multidisciplinary initiative is necessary to achieve safe and appropriate use of injections in Mongolia through (1) behavior change, (2) increasing availability of injection devices and sharps boxes, and (3) appropriate sharps waste management.