Immunisation uptake, services required and government incentives for users of formal day care

Enhancing Routine Childhood Vaccination Uptake in the Cape Metropolitan District, South Africa: Perspectives and Recommendations from Point-of-Care Vaccinators

Vaccination, and particularly childhood vaccination, is widely acknowledged as one of the greatest public health interventions in history. Nevertheless, challenges exist that threaten the progress of childhood vaccination in many parts of the world. We investigated challenges to vaccination experienced by point-of-care vaccinators in the Cape Town Metropolitan District (Cape Metro), and reported on their current and proposed efforts to combat these challenges. Semi-structured interviews were conducted with 19 vaccinators in 16 purposively selected healthcare facilities in the Cape Metro from September to November 2019. Interviews were transcribed and analysed using thematic and narrative analysis methods. Challenges of both the demand and the supply side of routine vaccination were reported by the study participants, as were contextual challenges such as community safety issues. Defaulting was the most common challenge encountered, reported by 16 of the 19 participants. The use of computerized appointment systems, the enlistment of community health workers to track down defaulters, and the use of certificates to incentivize caregivers are part of the creative ways of mitigating some of the challenges encountered by these vaccinators. Their insightful recommendations can positively influence the landscape of childhood vaccination uptake in the Cape Metro and beyond if adapted and applied.

Identification of the determinants of incomplete vaccination in Australian children

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Demographic/social factors, vaccine beliefs, and vaccination status were captured.

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Most parents are supportive of vaccination.

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Many parents incorrectly reported their child as fully vaccinated.

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Incomplete vaccination was associated with demographic and socio-economic factors.

Background and aims

We aimed to understand the risk factors associated with incomplete vaccination, which may help to identify and prioritise opportunities to intervene.

Methods

Consenting parents of children <6 years old attending an outpatient clinic completed a questionnaire, which captured demographic information and their level of agreement with belief statements about vaccination using a 7-point Likert scale. Vaccination status was determined from the Australian Childhood Immunisation Register and deemed either “complete” (no doses overdue) or “incomplete” (1 or more doses overdue) at the time of questionnaire completion.

Results

Of 589 children of respondents, 116 (20%) had an incomplete vaccination status. Of these, nearly two-thirds (63%) of parents believed that their child was, in fact, fully-vaccinated. Compared to those with a complete vaccine status, children with an incomplete vaccine status were more likely to be born overseas (p < 0.001), have a larger family size (p = 0.02) and to have parents with lower educational attainment (p = 0.001). Parents of children with an incomplete status reported more doubt about the importance of vaccination and greater concern about vaccine safety, compared to parents of children with a complete status.

Conclusion

Most parents are supportive of vaccination. Sociodemographic factors may contribute more to the risk of incomplete vaccination than attitudes or beliefs. Some parents are unaware of their child’s vaccination status, suggesting that simple and modern reminders may assist parents to keep up to date.

Factors associated with delayed infant immunization in a nationally representative cohort study

BACKGROUND

Many children in developed countries do not receive recommended vaccines on time. However, knowledge about factors related to timeliness remains limited. Quantifying the relative impact of parental attitudes compared with socio-demographic factors for delayed immunization would inform policy responses.

METHODS

Participants in the nationally representative Longitudinal Study of Australian Children were matched with their vaccination histories in the Australian Childhood Immunisation Register (N = 4,121). Information about the children and their families were collected in face-to-face interviews in 2003-2004. We considered whether children had completed the primary course for each recommended antigen due by 6 months old. Children were categorized as either fully immunized, delayed, or totally non-immunized. The outcome was examined using logistic regression. Population attributable fractions were estimated for key predictors.

RESULTS

Delayed immunization was significantly associated with indicators of social disadvantage as well as parental disagreement with immunization. Attributable fractions for delayed immunization included lone motherhood (3.8%; 95% confidence interval CI [0.8, 6.7]), larger family size (39.5%; 95% CI [31.2, 46.8]), residential mobility (3.3%; 95% CI [0.1, 6.5]), lack of private hospital insurance (9.4%; 95% CI [0.7, 17.3]), a medical condition in the child (2.0%; 95% CI [0.2, 3.9]), and parental disagreement with immunization (2.1%; 95% CI [0.3, 3.9]).

CONCLUSIONS

Parental attitudes accounted for a relatively small percentage of delayed infant immunization. In contrast, many children who did not receive vaccines on time were characterized by social disadvantage, especially larger family size. Researchers and policy-makers should consider how to make timely immunization easier for busy parents.

Tailoring immunisation service delivery in a disadvantaged community in Australia; views of health providers and parents

In 2014 the Australian immunisation target was raised from 90% to 95% of children to be fully immunised. A national priority is to identify geographic areas of low coverage and implement strategies to improve immunisation rates. Using The World Health Organization's Tailoring Immunization Programmes (TIP) Guidelines, the aim of this study was to identify areas of low immunisation coverage for children in the Hunter New England Local Health District, New South Wales, and to gain a deeper understanding of the factors influencing immunisation in those areas in order to develop tailored strategies for increasing immunisation coverage. Data from the Australian Immunisation Register was used to identify geographic areas of low coverage. Data from interviews and focus groups with parents and service providers were used to gain a deeper understanding of the factors influencing immunisation in those areas. The regional city of Maitland in New South Wales was identified as having a persistently high number and relatively high proportion of children not fully immunised (n = 427, 15.4% in 2016). Themes from 59 stakeholder interviews and focus groups included; (i) limited engagement with health services unless the need is urgent, (ii) multi-dimensional access barriers to immunisation services in Maitland, (iii) a flexible, supportive family centred, primary health care approach, utilising strong partnerships, is most likely to be effective in increasing childhood immunisation rates in Maitland, (iv) data can be used more effectively to inform service providers about trends and individual children not fully immunised. TIP guidelines proved useful for identifying areas of low coverage and providing an understanding of determining factors and the strategies most likely to be effective. Understanding the complex problems many parents face and the access barriers that contribute to low immunisation coverage is essential in developing appropriate solutions. Finding ways to support parents and remove those barriers can contribute to higher coverage. In Maitland, targeted outreach and home visiting has been implemented in consultation with community and health service representatives to ensure that the children from socially disadvantaged populations identified do not miss out on vaccination.

Determinants of under-immunization and cumulative time spent under-immunized in a Quebec cohort

BACKGROUND

Under-immunization refers to a state of sub-optimal protection against vaccine preventable diseases. Vaccine coverage for age may not capture intentional or non-intentional spacing of vaccines in the recommended provincial immunization guidelines. We aimed to identify factors associated with coverage and under-immunization and to determine the number of days during which children were under-immunized during their first 24months of life.

METHODS

Secondary analysis of children ≤3years recruited through active surveillance for gastroenteritis from three Quebec pediatric emergency departments from 2012 to 2014. Vaccination status for children at least 24months of age was determined using provincial immunization guidelines. Cumulative days under-immunized were calculated for DTaP-VPI-Hib, PCV, MMR, and Men-C-C. Factors associated with up-to-date (UTD) status at 24months of life and for under-immunization ≥6months were analyzed using logistic regression.

RESULTS

Of 246 eligible children, 180 (73%) were UTD by 24months of life. The mean cumulative days under-immunized for MMR was 107days, for PCV 209days, for Men-C-C 145days, and for DTaP-VPI-Hib 227days. Overall, 149 children (60%) experienced delay for at least 1 vaccine. Factors associated with both an UTD status at 24months and concurrently associated with being under-immunization ≥6months, included timely initiation of immunization (OR=5.85; 95% CI: 2.80-12.22) and (OR=0.13; 95% CI: 0.07-0.24), failure to co-administer 18-month vaccines (OR=0.15; 95% CI: 0.10-0.21) and (OR=3.29; 95% CI: 2.47-4.39), and having a household with ≥3 children under 18years ((OR=0.50; 0.28-0.86) and (OR=2.99; 1.45-6.22), respectively.

CONCLUSION

Paired with an unexpected low level of coverage at 24months of life, the majority of our cohort also experienced a state of under-immunization for a least one vaccine. Estimates of coverage do not capture intentional or non-intentional gaps in protection from vaccine preventable illnesses. Timely preventive care should be prioritized.

Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study and discrete choice experiment

BACKGROUND

Uptake of preschool vaccinations is less than optimal. Financial incentives and quasi-mandatory policies (restricting access to child care or educational settings to fully vaccinated children) have been used to increase uptake internationally, but not in the UK.

OBJECTIVE

To provide evidence on the effectiveness, acceptability and economic costs and consequences of parental financial incentives and quasi-mandatory schemes for increasing the uptake of preschool vaccinations.

DESIGN

Systematic review, qualitative study and discrete choice experiment (DCE) with questionnaire.

SETTING

Community, health and education settings in England.

PARTICIPANTS

Qualitative study - parents and carers of preschool children, health and educational professionals. DCE - parents and carers of preschool children identified as 'at high risk' and 'not at high risk' of incompletely vaccinating their children.

DATA SOURCES

Qualitative study - focus groups and individual interviews. DCE - online questionnaire.

REVIEW METHODS

The review included studies exploring the effectiveness, acceptability or economic costs and consequences of interventions that offered contingent rewards or penalties with real material value for preschool vaccinations, or quasi-mandatory schemes that restricted access to 'universal' services, compared with usual care or no intervention. Electronic database, reference and citation searches were conducted.

RESULTS

Systematic review - there was insufficient evidence to conclude that the interventions considered are effective. There was some evidence that the quasi-mandatory interventions were acceptable. There was insufficient evidence to draw conclusions on economic costs and consequences. Qualitative study - there was little appetite for parental financial incentives. Quasi-mandatory schemes were more acceptable. Optimising current services was consistently preferred to the interventions proposed. DCE and questionnaire - universal parental financial incentives were preferred to quasi-mandatory interventions, which were preferred to targeted incentives. Those reporting that they would need an incentive to vaccinate their children completely required around £110. Those who did not felt that the maximum acceptable incentive was around £70.

LIMITATIONS

Systematic review - a number of relevant studies were excluded as they did not meet the study design inclusion criteria. Qualitative study - few partially and non-vaccinating parents were recruited. DCE and questionnaire - data were from a convenience sample.

CONCLUSIONS

There is little current evidence on the effectiveness or economic costs and consequences of parental financial incentives and quasi-mandatory interventions for preschool vaccinations. Universal incentives are likely to be more acceptable than targeted ones. Preferences concerning incentives versus quasi-mandatory interventions may depend on the context in which these are elicited.

FUTURE WORK

Further evidence is required on (i) the effectiveness and optimal configuration of parental financial incentive and quasi-mandatory interventions for preschool vaccinations - if effectiveness is confirmed, further evidence is required on how to communicate this to stakeholders and the impact on acceptability; and (ii) the acceptability of parental financial incentive and quasi-mandatory interventions for preschool vaccinations to members of the population who are not parents of preschool children or relevant health professionals. Further consideration should be given to (i) incorporating reasons for non-vaccination into new interventions for promoting vaccination uptake; and (ii) how existing services can be optimised.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003192.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Parental financial incentives for increasing preschool vaccination uptake: systematic review

BACKGROUND AND OBJECTIVE

Financial incentives have been used to promote vaccination uptake but are not always viewed as acceptable. Quasimandatory policies, such as requiring vaccinations for school enrollment, are widely implemented in some countries. A systematic review was conducted to determine the effectiveness, acceptability, and economic costs and consequences of parental financial incentives and quasimandatory schemes for increasing the uptake of preschool vaccinations in high-income countries.

METHODS

Electronic databases and gray literature were searched for randomized controlled trials, controlled before-and-after studies, and time series analyses examining the effectiveness of parental financial incentives and quasimandatory schemes, as well as any empirical studies exploring acceptability. All included studies were screened for information on economic costs and consequences. Two reviewers independently assessed studies for inclusion, extracted data, and assessed the quality of selected articles by using established instruments. Studies were synthesized in narrative reviews.

RESULTS

Four studies on the effectiveness and 6 on the acceptability of parental financial incentives and quasimandatory interventions met the inclusion criteria. Only 1 study reported on costs and consequences. Studies of effectiveness had low risk of bias but displayed substantial heterogeneity in terms of interventions and methods.

CONCLUSIONS

There was insufficient evidence to conclude whether these interventions were effective. Studies of acceptability suggested a preference, in settings where this already occurs, for incentives linking vaccinations to access to education. There was insufficient evidence to draw conclusions on economic costs and consequences.

Predictors of incomplete immunisation in Victorian children

OBJECTIVE

Using probabilistic record linkage, this study aimed to determine the predictors of incomplete immunisation in Victorian children.

METHODS

Records of all births in Victoria in 1998 were linked with records from the Australian Childhood Immunisation Register (ACIR). The outcomes of interest were the predictors of immunisation status at 12 and 24 months of age.

RESULTS

A total of 91.1% of birth records were linked with records from the ACIR (n=55,129). Immunisation coverage was 92.8% at 12 months and 89.2% at 24 months. After multivariate analysis, the following maternal factors were significant predictors of incomplete immunisation in children aged 12 months: higher parity, 12-23 months interval between pregnancies, not being married, Aboriginal or Torres Strait Islander or born overseas, younger age, no private health insurance, home birth, metropolitan place of birth, and being in the highest or lowest socioeconomic quintiles. Low birthweight and singleton birth were also significant predictors. All of these factors were also predictive of incomplete immunisation in children aged 24 months, with the exception of low birth weight, which was only significant in the very low birth weight category. Congenital malformations or prematurity were not significant predictors.

CONCLUSIONS AND IMPLICATIONS

Record linkage is an effective means of determining the relationship between immunisation status and socio-demographic and health-related factors. It enabled small groups within a large population to be studied, confirming findings from previous survey studies and indicating that several population groups were at increased risk of incomplete immunisation. The main limitation of the study was the under-reporting of immunisation status to the ACIR.

Systematically reviewing qualitative studies complements survey design: an exploratory study of barriers to paediatric immunisations

BACKGROUND AND OBJECTIVES

Designing survey questions requires content expertise, awareness of previous qualitative literature, and piloting. We examined surveys addressing parental barriers to vaccinating children to determine if they comprehensively included themes identified in published qualitative studies.

METHODS

We performed a systematic literature search of 12 electronic databases and compared questions asked in eligible surveys identified to issues raised in qualitative studies. Issues included nine themes related to harm, six related to distrust, eight to issues of access, and three other issues.

RESULTS

The 29 eligible surveys failed to adequately address several important themes identified in qualitative studies. The number that failed to address the following themes were as follows: beliefs that vaccines cause diseases (n = 26); painful (n = 25); distrust of medical community (n = 28); communication problems with staff (n = 25); memories of their own or others adverse experiences (n = 28); fear of long-term effects (n = 26); belief the medical community does not understand adverse events associated with vaccines (n = 28); and parent's own lack of knowledge about diseases (n = 29).

CONCLUSIONS

Many surveys of parental barriers to immunization failed to address a number of important themes identified in qualitative studies. To the extent this is true in other areas, ensuring that investigators have conducted an adequate number and variety of qualitative studies, and systematically reviewing those studies, will improve surveys' content validity.

Increases in vaccination coverage for children in child care, 1997 to 2000: an evaluation of the impact of government incentives and initiatives

OBJECTIVE

To compare vaccination coverage of children in child care before (1997) and after (2000) implementation of government immunisation strategies including parent/providers incentives and surveillance of vaccination uptake.

METHODS

Cross-sectional parent surveys of vaccination coverage for children (<3 years old regularly attending child care) in 47 child care centres and 19 councils operating family day care in metropolitan Melboume.

RESULTS

Data were collected for 1,578 (72%) children in 1997 and 1,793 (72%) in 2000. In 2000, 93% were completely immunised, a 9% (95% CI 6%-11%, p<0.001) increase from 1997. Less than 1% of children were unimmunised (0.8% in 1997, 0.5% in 2000). For those >2 years, 94% were completely immunised before their second birthday in 2000 compared with 80% in 1997. Immunisation levels were 10% (95% Cl 6-12) higher in 2000 than in 1997 for those receiving child care benefits compared with a 7% (95% Cl 3-10) increase for families not receiving benefits. In 1997, 8 (17%) child care centres and 4 (21%) councils reported > or = 90% children completely immunised increasing to 33 (70%) and 16 (84%) in 2000 respectively. Fewer families reported delaying immunisations because of minor illness in 2000 (27%) compared to 1997 (44%, p<.001). Updating immunisation data by child care coordinators increased from 51% in 1997 to 98% in 2000.

CONCLUSION

A substantial increase in immunisation uptake has been achieved for this population of young children attending child care. This study provides evidence that the increase in vaccination rates is attributable to some extent to increased surveillance of immunisation rates and both parent and provider incentives to immunise.

A serosurvey evaluation of the school-based measles 'catch-up' immunisation campaign in Victorian school-aged children

OBJECTIVE

To determine the proportion of Victorian primary school students protected against measles infection one year after the completion of the measles 'catch-up' immunisation campaign of 1998 and to compare this with the proportion of year 9 and 10 (aged 14-16 years) students.

DESIGN & SETTING

Three-stage random cluster survey in Victorian primary and secondary schools.

MAIN OUTCOME MEASURES

Proportion of primary and year 9 and 10 secondary school students protected against measles infection one year after the completion of the mass 'catch-up' immunisation campaign.

SECONDARY OUTCOMES

the proportion of both primary and year 9 and 10 secondary school students protected against both mumps and rubella.

RESULTS

Of 1,037 Victorian primary and 2,357 years 9 and 10 secondary school students invited to participate in this study, 403 (39%) and 752 (32%) respectively provided a blood specimen for serological testing for antibodies against measles, mumps and rubella. 94.8% (95% confidence interval, 91.5, 96.9) of primary school and 93.1% (90.9, 94.8) of year 9 and 10 students were protected against measles infection.

CONCLUSION

One year after the completion of the school-based measles 'catch-up' immunisation campaign the level of protection in Victorian primary school aged students is sufficient to prevent the continuing circulation of measles virus within this age group. The proportion of year 9 and 10 secondary school students protected against measles is also probably sufficient to prevent continuing circulation of wild type virus in Victoria, even though this age group was not specifically targeted by the 'catch-up' campaign.