Engaging communities with a simple tool to help increase immunization coverage.

The level of vaccination coverage in a given community depends on both service factors and the degree to which the public understands and trusts the immunization process. This article describes an approach that aims to raise awareness and boost demand. Developed in India, the "My Village Is My Home" (MVMH) tool, known as Uma Imunizasaun (UI) in Timor-Leste, is a poster-sized material used by volunteers and health workers to record the births and vaccination dates of every infant in a community. Introduction of the tool in 5 districts of India (April 2012 to March 2013) and in 7 initial villages in Timor-Leste (beginning in January 2012) allowed community leaders, volunteers, and health workers to monitor the vaccination status of every young child and guided reminder and motivational visits. In 3 districts of India, we analyzed data on vaccination coverage and timeliness before and during use of the tool; in 2 other districts, analysis was based only on data for new births during use of the tool. In Timor-Leste, we compared UI data from the 3 villages with the most complete data with data for the same villages from the vaccination registers from the previous year. In both countries, we also obtained qualitative data about perceptions of the tool through interviews with health workers and community members. Assessments in both countries found evidence suggesting improved vaccination timeliness and coverage. In India, pilot communities had 80% or higher coverage of identified and eligible children for all vaccines. In comparison, overall coverage in the respective districts during the same time period was much lower, at 49% to 69%. In Timor-Leste, both the number of infants identified and immunized rose substantially with use of the tool compared with the previous year (236 vs. 155, respectively, identified as targets; 185 vs. 147, respectively, received Penta 3). Although data challenges limit firm conclusions, the experiences in both countries suggest that "My Village Is My Home" is a promising tool that has the potential to broaden program coverage by marshalling both community residents and health workers to track individual children's vaccinations. Three states in India have adopted the tool, and Timor-Leste had also planned to scale-up the initiative.

New vaccine introductions: assessing the impact and the opportunities for immunization and health systems strengthening.

In 2010, global immunization partners posed the question, "Do new vaccine introductions (NVIs) have positive or negative impacts on immunization and health systems of countries?" An Ad-hoc Working Group was formed for WHO's Strategic Advisory Group of Experts on immunization (SAGE) to examine this question through five approaches: a published literature review, a grey literature review, in-depth interviews with regional and country immunization staff, in-depth studies of recent NVIs in 3 countries, and a statistical analysis of the impact of NVI on DTP3 coverage in 176 countries. The WHO Health System Framework of building blocks was used to organize the analysis of these data to assess potential areas of impact of NVI on health systems. In April 2012, the Ad-hoc Working Group presented its findings to SAGE. While reductions in disease burden and improvements in disease and adverse events surveillance, training, cold chain and logistics capacity and injection safety were commonly documented as beneficial impacts, opportunities for strengthening the broader health system were consistently missed during NVI. Weaknesses in planning for human and financial resource needs were highlighted as a concern. Where positive impacts on health systems following NVI occurred, these were often in areas where detailed technical guidance or tools and adequate financing were available. SAGE supported the Ad-hoc Working Group's conclusion that future NVI should explicitly plan to optimize and document the impact of NVI on broader health systems. Furthermore, opportunities for improving integration of delivery of immunization services, commodities, and messages with other parts of the health system should be actively sought with the recognition that integration is a bidirectional process. To avoid the gaps in planning for NVI that can compromise existing immunization and health systems, donors and partners should provide sufficient and timely support to facilitate country planning. Areas for future research were also identified. Finally, to support countries in using NVI as an opportunity to strengthen immunization and health systems, the WHO guidance for countries on new vaccine introduction is being updated to reflect ways this might be accomplished.

Factors limiting immunization coverage in urban Dili, Timor-Leste.

BACKGROUND: Timor-Leste's immunization coverage is among the poorest in Asia. The 2009/2010 Demographic and Health Survey found that complete vaccination coverage in urban areas, at 47.7%, was lower than in rural areas, at 54.1%. The city of Dili, the capital of Timor-Leste, had even lower coverage (43.4%) than the national urban average. OBJECTIVE: To better understand the service- and user-related factors that account for low vaccination coverage in urban Dili, despite high literacy rates and relatively good access to immunization services and communication media. METHODS: A mixed-methods (mainly qualitative) study, conducted in 5 urban sub-districts of Dili, involved in-depth interviews with18 Ministry of Health staff and 6 community leaders, 83 observations of immunization encounters, 37 exit interviews with infants' caregivers at 11 vaccination sites, and 11 focus group discussions with 70 caregivers of vaccination-eligible children ages 6 to 23 months. RESULTS: The main reasons for low vaccination rates in urban Dili included caregivers' knowledge, attitudes, and perceptions as well as barriers at immunization service sites. Other important factors were access to services and information, particularly in the city periphery, health workers' attitudes and practices, caregivers' fears of side effects, conflicting priorities, large family size, lack of support from husbands and paternal grandmothers, and seasonal migration. CONCLUSION: Good access to health facilities or health services does not necessarily translate into uptake of immunization services. The reasons are complex and multifaceted but in general relate to the health services' insufficient understanding of and attention to their clients' needs. Almost all families in Dili would be motivated to have their children immunized if services were convenient, reliable, friendly, and informative.

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.

Speeding up child immunization

This article outlines some ways in which it has been possible to improve immunization coverage. With regard to accelerated national campaigns, careful planning at an early stage is vital if the potential benefits are to be fully realized