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Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization
Hussain R Usman1, Mohammad H Rahbar, Sibylle Kristensen
1Department of Epidemiology, University of Alabama, Birmingham, AL, USA. hussain@uab.edu
Insights
Improved immunization cards and mother education significantly increased DTP3 completion rates in Pakistan. These interventions show promise for boosting childhood immunization coverage in the Expanded Programme on Immunization (EPI) system.
Area of Science:
- Public Health
- Pediatrics
- Global Health
Background:
- High dropout rates from the first dose (DTP1) to the third dose (DTP3) of diphtheria-tetanus-pertussis immunization are a significant challenge in Pakistan.
- The Expanded Programme on Immunization (EPI) in Pakistan faces challenges in ensuring complete vaccination schedules.
Purpose of the Study:
- To evaluate the effectiveness of a redesigned immunization card, center-based education for mothers, or a combination of both interventions in improving DTP3 completion rates.
- To assess the impact of these interventions on DTP3 completion at rural EPI centers in Pakistan.
Main Methods:
- A randomized controlled trial was conducted with mother-child pairs enrolled at DTP1.
- Participants were randomized into four groups: redesigned card, center-based education, combined intervention, and standard care.
- Children were followed for 90 days to record DTP2 and DTP3 vaccination dates, with DTP3 completion as the primary outcome.
Main Results:
- DTP3 completion rates were 39% in the standard care group.
- Significantly higher DTP3 completion rates were observed in the intervention groups: redesigned card (66%), center-based education (61%), and combined intervention (67%).
- Crude risk ratios (RR) indicated substantial improvements with interventions (RR=1.7 for card, RR=1.5 for education, RR=1.7 for combined).
Conclusions:
- Both the improved immunization card and mother education interventions, individually or combined, effectively increased follow-up immunization visits.
- The study highlights the public health potential of these interventions for improving childhood immunization coverage.
- Further large-scale evaluation within the EPI system is recommended to assess their impact on the complete immunization schedule.
Objective:
A substantial dropout from the first dose of diphtheria-tetanus-pertussis (DTP1) to the 3rd dose of DTP (DTP3) immunization has been recorded in Pakistan. We conducted a randomized controlled trial to assess the effects of providing a substantially redesigned immunization card, centre-based education, or both interventions together on DTP3 completion at six rural expanded programme on immunization (EPI) centres in Pakistan.
Methods:
Mother-child pairs were enrolled at DTP1 and randomized to four study groups: redesigned card, centre-based education, combined intervention and standard care. Each child was followed up for 90 days to record the dates of DTP2 and DTP3 visits. The study outcome was DTP3 completion by the end of follow-up period in each study group.
Results:
We enrolled 378 mother-child pairs in redesigned card group, 376 in centre-based education group, 374 in combined intervention group and 378 in standard care group. By the end of follow-up, 39% of children in standard care group completed DTP3. Compared to this, a significantly higher proportion of children completed DTP3 in redesigned card group (66%) (crude risk ratio [RR] = 1.7; 95% CI = 1.5, 2.0), centre-based education group (61%) (RR = 1.5; 95% CI = 1.3, 1.8) and combined intervention group (67%) (RR = 1.7; 95% CI = 1.4, 2.0).
Conclusions:
Improved immunization card alone, education to mothers alone, or both together were all effective in increasing follow-up immunization visits. The study underscores the potential of study interventions' public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system.
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