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Shaikh BT. Universal health coverage in Pakistan: exploring the landscape of the health system, health seeking behaviours, and utilization of health services. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 27:100440. [PMID: 39015938 PMCID: PMC11251088 DOI: 10.1016/j.lansea.2024.100440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/21/2024] [Accepted: 06/10/2024] [Indexed: 07/18/2024]
Abstract
The attainment of the noble objective of Universal Health Coverage (UHC)- 'leaving no one behind' necessitates sufficient financial resources, an ample supply of skilled healthcare professionals, and the availability of essential services as part of a basic package This paper presents an analysis of the health system, health seeking behaviours and health service utilization en route to UHC in Pakistan. We have used the UHC 14 tracer indicators of service coverage to see where Pakistan stands, what are the gaps and what needs to be done. Pakistan clearly is lagging behind its neighboring countries. The country's health system ought to work on health seeking behaviours and broader determinants of health. The pursuit of UHC demands a shared responsibility and collective action, with stakeholders from different sectors uniting their efforts and expertise. Together, they can establish robust systems, design comprehensive policies, allocate adequate resources, and implement interventions that transcend disciplinary boundaries.
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Zarzeczny A, Kahar P. Vaccine Trends in Pakistan: A Review of Immunization Challenges and Setbacks Prompted by Inadequate Disaster Management. Cureus 2024; 16:e55357. [PMID: 38562365 PMCID: PMC10982083 DOI: 10.7759/cureus.55357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/04/2024] Open
Abstract
Pakistan bears an incredible burden of vaccine-preventable diseases, and efforts to improve widespread immunization have been hindered by inadequate public health management following disasters and other health emergencies. Through a brief review of Pakistan's health system, an understanding of routine immunization challenges is sought based on the organizational changes made to the planning and delivery of immunization activities. Further, recent immunization trends of measles, polio, and tuberculosis are examined in correspondence to health emergencies prompted by climate change and the COVID-19 pandemic. The national public health response to each disease is discussed, and insight is given to how the devolution of Pakistan's health system may have influenced the severity of each emergency. Focus is given to the potential immunization challenges and how they may impact future initiatives for the control of vaccine-preventable diseases. Although incidence rates suggest increased cases of certain vaccine-preventable diseases and disruptions of immunization activities following recent disasters, further studies may need to be conducted to establish a stronger understanding of the immunization trends noted within this review.
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Affiliation(s)
| | - Payal Kahar
- Health Sciences, Florida Gulf Coast University, Fort Myers, USA
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Ullah K, Saleem J, Zakar R, Ishaq M, Khattak FA, Majeed F, Sadiqa HA, Fischer F. Exploring the reasons for defaulting from childhood immunization: a qualitative study in Pakistan. BMC Public Health 2024; 24:408. [PMID: 38331754 PMCID: PMC10851579 DOI: 10.1186/s12889-024-17926-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Childhood vaccination is widely recognized as the most effective means to prevent various diseases. However, a considerable amount of children still miss out on their vaccination schedules. Therefore, this study explores the reasons for defaulting from the expanded program on immunization in district Swat, Pakistan. METHODS A qualitative phenomenological approach was used. Data collection took place from March to September 2022. Thirty-six in-depth interviews were conducted with participants who had defaulter children. The collected qualitative data were analysed thematically to identify key patterns and themes related to the reasons for defaulting from childhood vaccination schedules. RESULTS Six themes emerged, i.e., illness of the defaulter child at the scheduled time, perceived side effects of the vaccination, factors related to caregivers, myths and misconceptions, vaccinators attitudes and crowed vaccination centres, as well as poor immunization service arrangements. Four subthemes arose related to caregivers, such as lack of clear understanding about completion of vaccination, least priority for child's vaccination, cultural restriction on mothers, and the loss of vaccination card. CONCLUSION According to the study's findings, caregivers have their own perceptions regarding the non-completion of their children's vaccination schedule. The childhood immunization defaulting arises from various factors including child illness, Adverse Events Following Immunization (AEFIs) concerns, misconceptions, improper injection techniques, and negative vaccinator attitudes. The vaccination completion rate may be increased if the concerns of the caregivers are appropriately addressed.
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Affiliation(s)
- Kifayat Ullah
- Department of Public Health, Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Javeria Saleem
- Department of Public Health, Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Rubeena Zakar
- Department of Public Health, Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Muhammad Ishaq
- Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | | | - Fatima Majeed
- Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Hafiza Aisha Sadiqa
- Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Florian Fischer
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
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Macredie F, Willing E, Dawson P, Howe A, Young A. Interventions to improve vaccine coverage of pregnant women in Aotearoa New Zealand. J Prim Health Care 2023; 15:230-237. [PMID: 37756230 DOI: 10.1071/hc23041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/20/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Maternal vaccination against influenza and pertussis protects mothers and babies from severe disease and is recommended and funded in Aotearoa New Zealand. Despite this, maternal vaccination uptake is low, varies by region and is inequitable, with Māori and Pacific māmā (mothers) less likely to receive vaccination. Aim To determine what interventions currently exist to support and encourage maternal vaccination against influenza and pertussis and what changes and interventions could be implemented to improve coverage, with a focus on Māori and Pacific hapū māmā (pregnant mothers). Methods Interviews with six participants with diverse roles in the vaccination workforce were conducted. Participants were involved in education, certification and supporting vaccinators, high-level strategising, and vaccination. Interviews aimed to determine what interventions currently exist for hapū māmā, what changes need to be made to improve coverage and how Māori and Pacific people have been specifically engaged. Qualitative data analysis was used to determine themes. Results Participants identified that interventions must focus on prioritising and emphasising the importance of maternal vaccination, promoting collaboration and innovation, making interventions accessible, and empowering Māori- and Pacific-driven avenues to vaccination. To create positive foundations, participants identified the importance of building and maintaining trust and affording mothers' time and autonomy in vaccination. Discussion Healthcare professionals need to proactively engage hapū māmā about vaccination and collaborate in service delivery. Interventions must be suitably accessible and allow for the autonomy of hapū māmā over vaccination decisions. Equity should be considered at the foundation of vaccine interventions to improve the accessibility of vaccines to all communities.
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Affiliation(s)
- Flynn Macredie
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Esther Willing
- Kohatu - The Centre for Hauora Maori, University of Otago, Dunedin, New Zealand
| | - Pauline Dawson
- Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Anna Howe
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Amber Young
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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Qasim R, Farooqui WA, Rahman A, Haroon R, Saleem M, Rafique M, Noor F, Ghani A, Yaqoob M, Yadav UN, Yousafzai MT. Community centred co-design methodology for designing and implementing socio-behavioural interventions to counter COVID-19 related misinformation among marginalized population living in the squatter settlements of Karachi, Pakistan: a methodology paper. BMC Proc 2023; 17:15. [PMID: 37438805 DOI: 10.1186/s12919-023-00265-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Misinformation regarding COVID-19 pandemic and vaccination is damaging COVID-19 vaccine trust and acceptance in Low- and Middle-Income Countries (LMIC). Identification of misinformation and designing locally acceptable solutions are needed to improve COVID-19 vaccine acceptance. This study aimed to utilize community-led co-design methodology to evaluate misinformation regarding COVID-19 and develop contextual interventions to address misinformation in a marginalized peri urban slum communities of Landhi town Karachi, Pakistan. METHODS This study was conducted between January and December 2021, in marginalized peri-urban slum dwellers of Muslimabad Colony, Landhi Town Karachi, Pakistan. We used a community-centred co-design methodology embedded within mixed study design to identify misinformation, co-design, test and implement locally acceptable solutions. The co-design methodology involved five stages of the design thinking model: (1) Empathize, (2) Define, (3) Ideate, (4) Prototype, and (5) Test. The project involved active engagement and participation of wide range of stakeholders and community beneficiaries (end users) including local EPI vaccinators, informal healthcare workers, religious leaders (male and female), schoolteachers (male and female), local government representatives, community leaders, housewives, youth, and general population. To develop a trusting relationship, and understand local culture, values, practices, and traditions, we allowed one month of observation period (observe, engage, watch, and listen) in the beginning, followed by door-to-door survey along with focus group discussions (FGD) and in-depth interviews (IDI) at baseline. Co-design workshops (separate for male and female) were conducted at each stage of co-design methodology to design and test locally acceptable solutions. CONCLUSION Community-centred co-design methodology was not only successful in designing, testing, and evaluating locally acceptable solutions but it also actively engaged and empowered the marginalized population living in peri urban slum communities of Karachi, Pakistan.
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Affiliation(s)
- Rubina Qasim
- Dow Institute of Nursing & Midwifery, Dow University of Health Sciences, Karachi, Pakistan.
| | | | - Atiya Rahman
- Indus College of Medical Technology & Allied Health, The Indus Hospital, Karachi, Pakistan
| | - Rukhsana Haroon
- Dow Institute of Nursing & Midwifery, Dow University of Health Sciences, Karachi, Pakistan
| | - Madiha Saleem
- Dow Institute of Nursing & Midwifery, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Rafique
- Indus College of Nursing & Midwifery, The Indus Hospital, Karachi, Pakistan
| | - Fiza Noor
- Indus College of Nursing & Midwifery, The Indus Hospital, Karachi, Pakistan
| | - Afifa Ghani
- Dept. of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Muhammad Yaqoob
- Dow Institute of Nursing & Midwifery, Dow University of Health Sciences, Karachi, Pakistan
| | - Uday Narayan Yadav
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
- National Centre for Epidemiology and Population Health, The Australian National University, ACT, Canberra, Australia
| | - Mohammad T Yousafzai
- Dept. of Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
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Shahid S, Ahmed S, Qazi MF, Ali R, Ali SA, Zaidi AKM, Iqbal NT, Jehan F, Imran Nisar M. Differential coverage for vaccines in the expanded program on immunization (EPI) among children in rural Pakistan. Vaccine 2023; 41:2680-2689. [PMID: 36933984 PMCID: PMC10124121 DOI: 10.1016/j.vaccine.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Pakistan has a well-established Expanded Program on Immunization (EPI) however vaccine-preventable diseases still account for high infant and child mortality rates. This study describes the differential vaccine coverage and determinants of vaccine uptake in rural Pakistan. METHODS From October 2014 to September 2018, we enrolled children younger than 2 years of age from the Matiari Demographic Surveillance System in Sindh, Pakistan. Socio-demographic and vaccination history were collected from all participants. Vaccine coverage rates and timeliness were reported. Socio-demographic variables for missed and untimely vaccination were studied in multivariable logistic regression. RESULTS Of the 3140 enrolled children, 48.4 % received all EPI recommended vaccines. Only 21.2 % of these were age appropriate. Around 45.4 % of the children were partially vaccinated, and 6.2 % were unvaccinated. Highest coverage was seen for the first dose of pentavalent (72.8 %), 10-valent Pneumococcal Conjugate Vaccine (PCV10) (70.4 %) and Oral Polio Vaccine (OPV) (69.2 %) and the lowest coverage was for measles (29.3 %) and rotavirus (1.8 %) vaccines. Primary caretakers and wage earners with a higher level of education were protective against missed and untimely vaccination. Enrollment in the 2nd, 3rd and 4th study year was negatively associated with being unvaccinated whereas distance from a major road was positively associated with non-adherence to schedule. CONCLUSION Vaccine coverage was low among children in Matiari, Pakistan, and majority received delayed doses. Parents' education status and year of study enrollment was protective against vaccine dropout and delayed vaccination whereas geographical distance from a major road was a predictor. Vaccine promotion and outreach efforts may have had a beneficial impact on vaccine coverage and timeliness.
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Affiliation(s)
- Shahira Shahid
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Rafey Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Anita K M Zaidi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan; Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Najeeha T Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fyezah Jehan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Muhammad Imran Nisar
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
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Ezezika O, Mengistu M, Opoku E, Farheen A, Chauhan A, Barrett K. What are the barriers and facilitators to polio vaccination and eradication programs? A systematic review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001283. [PMID: 36962654 PMCID: PMC10022167 DOI: 10.1371/journal.pgph.0001283] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022]
Abstract
Global efforts to eradicate polio by the Global Polio Eradication Initiative agency partners and country-level stakeholders have led to the implementation of global polio vaccination programs. This study presents the findings of existing studies regarding the barriers and facilitators that countries face when implementing polio interventions. A comprehensive search was conducted in OVID Medline, OVID Embase, EBSCO CINAHL Plus, and Web of Science. Eligible studies underwent quality assessment. A qualitative evidence synthesis approach was conducted and aligned to the Consolidated Framework for Implementation Research (CFIR). The search identified 4147 citations, and following the removal of duplicates and screening according to our inclusion/exclusion criteria, 20 articles were eligible for inclusion in the review. Twelve countries were represented in this review, with India, Nigeria, Pakistan, Ethiopia, and Afghanistan having the most representation of available studies. We identified 36 barriers and 16 facilitators. Seven themes emerged from these barriers and facilitators: fear, community trust, infrastructure, beliefs about the intervention, influential opinions, intervention design, and geo-politics. The most frequently cited CFIR constructs for the facilitators and barriers were knowledge and beliefs about the intervention, followed by available resources. This study identified a wide range of barriers and facilitators to polio vaccination implementation across the globe, adding to the scarce body of literature on these barriers and facilitators from an implementation perspective and using a determinant framework. The diversity of factors among different groups of people or countries highlights the relevance of contexts. Implementers should be conversant with the contexts within which polio eradication programs boost intervention coverage and capacity. This study provides policymakers, practitioners, and researchers with a tool for planning and designing polio immunization programs. Trial registration: A protocol for this systematic review was developed and uploaded onto the PROSPERO international prospective register of systematic reviews database (Registration number: CRD42020222115).
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Affiliation(s)
- Obidimma Ezezika
- School of Health Studies, Faculty of Health Sciences, University of Western Ontario, London, Canada
- Department of Health and Society, University of Toronto Scarborough, Toronto, Canada
- African Centre for Innovation and Leadership Development, Abuja, Nigeria
| | - Meron Mengistu
- Department of Health and Society, University of Toronto Scarborough, Toronto, Canada
- London School of Hygiene & Tropical Medicine, Keppel St, London, United Kingdom
| | - Eric Opoku
- Department of Health and Society, University of Toronto Scarborough, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Aiman Farheen
- Department of Health and Society, University of Toronto Scarborough, Toronto, Canada
| | - Anuradha Chauhan
- Department of Health and Society, University of Toronto Scarborough, Toronto, Canada
| | - Kathryn Barrett
- School of Health Studies, Faculty of Health Sciences, University of Western Ontario, London, Canada
- University of Toronto Scarborough Library, Toronto, Canada
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Jamison AF, McCormick BJJ, Hussain E, Thomas ED, Azam SI, Hansen CL, Rasmussen ZA. Determinants of vaccine coverage and timeliness in a northern Pakistani village. PLoS One 2022; 17:e0263712. [PMID: 35176050 PMCID: PMC8853560 DOI: 10.1371/journal.pone.0263712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 01/25/2022] [Indexed: 11/19/2022] Open
Abstract
The incidence of vaccine preventable disease in Pakistan remains high despite a long-standing Expanded Program on Immunization (EPI). We describe vaccine completeness, timeliness and determinants of coverage from a remote rural cohort (2012–2014). Vaccination histories were taken from EPI records. Vaccination was complete if all doses were received according to the EPI schedule and timely if doses were not ≥3 days early or ≥ 28 days late. Three models are presented: a multivariable logistic regression of household demographic and socioeconomic factors associated with complete vaccination, a multivariable mixed effects logistic regression assessing whether or not the vaccine was administered late (versus on-time), and a mixed effects multivariable Poisson regression model analysing the interval (in days) between vaccine doses. Of 959 enrolled children with full vaccination histories, 88.2 and 65.1% were fully vaccinated following either the pentavalent or DPT/HBV schedules if measles was excluded; coverage dropped to 50.0 and 27.1% when both doses of measles were included. Sixty-four (6.7%) were unvaccinated. Coverage and timeliness declined with subsequent doses. Migrating into the village after 1995 (95%CI 1.88 to 5.17) was associated with late vaccination. Being male, having an older father, and having parents with at least some formal education reduced the likelihood of a late dose. The interval between doses was consistent at 5 weeks (compared with the 4 weeks recommended by EPI). None of the socio-demographic variables were related to the likelihood of receiving full coverage. Vaccine coverage in Oshikhandass was higher than national averages. Measles vaccine coverage and timeliness were low; special consideration should be paid to this vaccine. The local vaccination schedule differed from the EPI, but the consistency suggests good local administration.
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Affiliation(s)
- Alexandra F. Jamison
- Division of International Epidemiology and Population Studies, Fogarty International Center, Bethesda, MD, United States of America
| | | | - Ejaz Hussain
- Administration Department, Karakoram International University, Gilgit, Gilgit-Baltistan, Pakistan
| | - Elizabeth D. Thomas
- Division of International Epidemiology and Population Studies, Fogarty International Center, Bethesda, MD, United States of America
| | - Syed Iqbal Azam
- Department of Community Health Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | - Chelsea L. Hansen
- Division of International Epidemiology and Population Studies, Fogarty International Center, Bethesda, MD, United States of America
| | - Zeba A. Rasmussen
- Division of International Epidemiology and Population Studies, Fogarty International Center, Bethesda, MD, United States of America
- * E-mail:
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Usability and Acceptability of a Mobile App for Behavior Change and to Improve Immunization Coverage among Children in Pakistan: A Mixed-Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189527. [PMID: 34574452 PMCID: PMC8469714 DOI: 10.3390/ijerph18189527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/30/2021] [Accepted: 09/02/2021] [Indexed: 01/22/2023]
Abstract
Background: Pakistan’s immunization uptake rates are still significantly lower than anticipated despite several initiatives. Lack of awareness, forgetting about vaccination schedule, and vaccine misconception/misinformation are a few of the major drivers that mitigate the rates of immunization. The current COVID-19 pandemic emphasizes the importance of immunization. The significant reductions in regular childhood vaccination during pandemic have increased the risk of outbreaks of vaccine-preventable diseases. Concerns among parents over possibly exposing their children to COVID-19 during child visits may have contributed to the reported declines. Innovative and cost-effective mHealth interventions must be implemented in order to address the problem of inadequate immunization rates. In addition, it is also critical to understand the end user needs in order to reflect on the highly relevant essence of the customized healthcare experience. Objective: The aim of this study was to learn about caregivers’ attitudes toward the usability and acceptability of behavior-change smartphone applications (mobile phones) for improving immunization coverage in Pakistan. Methods: A mixed-method design was employed for this study. The study was conducted at Aga Khan University, Hospital. Parents visiting the Community Health Center for 6-week vaccination of their children were recruited. The study was conducted in two stages. Stage 1 consisted of qualitative interviews that grasped the parent’s attitudes and challenges to immunization, as well as their acceptability and accessibility of the smartphone-based behavior-change application to increase vaccine uptake. Stage 1 was followed by stage 2, in which data were collected through a questionnaire designed by using data from qualitative interviews. Results: The majority of participants agreed that immunization serves an important role in protecting their child from illnesses that cause morbidity and mortality. Almost all of them emphasized the importance of using a pre-appointment method at vaccination center in order to reduce the waiting time. Furthermore, participants were also interested in AI-based behavior modification applications related to immunization. They also wanted to have applications in their native language for better understanding and communication of related information. In our study, approximately 95.2 percent of participants agreed to accept SMS immunization updates, which was also reasonably high. Lastly, the majority of them identified forgetfulness as a significant contributor to regular immunization. Conclusion: To enhance the uptake of childhood vaccines, overall vaccination rates, and overcome barriers related to vaccination coverage, cost-effective and user-friendly mHealth AI-based smart phone applications are required to raise awareness regarding the continuation of vaccination service and the importance of timely vaccination. Parents’ experiences and attitudes must be considered while designing and evaluating the efficacy of mHealth-based interventions.
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Decouttere C, De Boeck K, Vandaele N. Advancing sustainable development goals through immunization: a literature review. Global Health 2021; 17:95. [PMID: 34446050 PMCID: PMC8390056 DOI: 10.1186/s12992-021-00745-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 07/23/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Immunization directly impacts health (SDG3) and brings a contribution to 14 out of the 17 Sustainable Development Goals (SDGs), such as ending poverty, reducing hunger, and reducing inequalities. Therefore, immunization is recognized to play a central role in reaching the SDGs, especially in low- and middle-income countries (LMICs). Despite continuous interventions to strengthen immunization systems and to adequately respond to emergency immunization during epidemics, the immunization-related indicators for SDG3 lag behind in sub-Saharan Africa. Especially taking into account the current Covid19 pandemic, the current performance on the connected SDGs is both a cause and a result of this. METHODS We conduct a literature review through a keyword search strategy complemented with handpicking and snowballing from earlier reviews. After title and abstract screening, we conducted a qualitative analysis of key insights and categorized them according to showing the impact of immunization on SDGs, sustainability challenges, and model-based solutions to these challenges. RESULTS We reveal the leveraging mechanisms triggered by immunization and position them vis-à-vis the SDGs, within the framework of Public Health and Planetary Health. Several challenges for sustainable control of vaccine-preventable diseases are identified: access to immunization services, global vaccine availability to LMICs, context-dependent vaccine effectiveness, safe and affordable vaccines, local/regional vaccine production, public-private partnerships, and immunization capacity/capability building. Model-based approaches that support SDG-promoting interventions concerning immunization systems are analyzed in light of the strategic priorities of the Immunization Agenda 2030. CONCLUSIONS In general terms, it can be concluded that relevant future research requires (i) design for system resilience, (ii) transdisciplinary modeling, (iii) connecting interventions in immunization with SDG outcomes, (iv) designing interventions and their implementation simultaneously, (v) offering tailored solutions, and (vi) model coordination and integration of services and partnerships. The research and health community is called upon to join forces to activate existing knowledge, generate new insights and develop decision-supporting tools for Low-and Middle-Income Countries' health authorities and communities to leverage immunization in its transformational role toward successfully meeting the SDGs in 2030.
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Affiliation(s)
- Catherine Decouttere
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
| | - Kim De Boeck
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
| | - Nico Vandaele
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
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Akinyemi OO, Adebayo A, Bassey C, Nwaiwu C, Kalbarczyk A, Fatiregun AA, Alonge OO, Owoaje E. Assessing community engagement in Nigeria polio eradication initiative: application of the Consolidated Framework for Implementation Research. BMJ Open 2021; 11:e048694. [PMID: 34373306 PMCID: PMC8354285 DOI: 10.1136/bmjopen-2021-048694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study employed the Consolidated Framework for Implementation Research (CFIR) to assess factors that enhanced or impeded the implementation of community engagement strategies using the Nigerian polio programme as a point of reference. DESIGN This study was a part of a larger descriptive cross-sectional survey. The CFIR was used to design the instrument which was administered through face-to-face and phone interviews as well as a web-based data collection platform, Qualtrics. SETTING The study took place in at least one State from each of the six geopolitical zones in Nigeria (Nasarawa, Borno, Kano, Sokoto, Anambra, Bayelsa, Lagos, Ondo and Oyo States as well as the Federal Capital Territory). PARTICIPANTS The respondents included programme managers, policy-makers, researchers and frontline field implementers affiliated with the Global Polio Eradication Initiative (PEI) core partner organisations, the three tiers of the government health parastatals (local, state and federal levels) and academic/research institutions. RESULTS Data for this study were obtained from 364 respondents who reported participation in community engagement activities in Nigeria's PEI. Majority (68.4%) had less than 10 years' experience in PEI, 57.4% were involved at the local government level and 46.9% were team supervisors. Almost half (45.0%) of the participants identified the process of conducting the PEI program and social environment (56.0%) as the most important internal and external contributor to implementing community engagement activities in the community, respectively. The economic environment (35.7%) was the most frequently reported challenge among the external challenges to implementing community engagement activities. CONCLUSION Community engagement strategies were largely affected by the factors relating to the process of conducting the polio programme, the economic environment and the social context. Therefore, community engagement implementers should focus on these key areas and channel resources to reduce obstacles to achieve community engagement goals.
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Affiliation(s)
| | - Adedamola Adebayo
- Department of Community Medicine, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | - Christopher Bassey
- Department of Community Medicine, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | - Chioma Nwaiwu
- Department of Community Medicine, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | - Anna Kalbarczyk
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Akinola A Fatiregun
- Ondo State Field Office, World Health Organization Country Office for Nigeria, Ondo, Nigeria
| | - Olakunle O Alonge
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eme Owoaje
- Department of Community Medicine, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
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Ozawa S, Yemeke TT, Mitgang E, Wedlock PT, Higgins C, Chen HH, Pallas SW, Abimbola T, Wallace A, Bartsch SM, Lee BY. Systematic review of the costs for vaccinators to reach vaccination sites: Incremental costs of reaching hard-to-reach populations. Vaccine 2021; 39:4598-4610. [PMID: 34238610 PMCID: PMC10680154 DOI: 10.1016/j.vaccine.2021.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/07/2021] [Accepted: 05/06/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Economic evidence on how much it may cost for vaccinators to reach populations is important to plan vaccination programs. Moreover, knowing the incremental costs to reach populations that have traditionally been undervaccinated, especially those hard-to-reach who are facing supply-side barriers to vaccination, is essential to expanding immunization coverage to these populations. METHODS We conducted a systematic review to identify estimates of costs associated with getting vaccinators to all vaccination sites. We searched PubMed and the Immunization Delivery Cost Catalogue (IDCC) in 2019 for the following costs to vaccinators: (1) training costs; (2) labor costs, per diems, and incentives; (3) identification of vaccine beneficiary location; and (4) travel costs. We assessed if any of these costs were specific to populations that are hard-to-reach for vaccination, based on a framework for examining supply-side barriers to vaccination. RESULTS We found 19 studies describing average vaccinator training costs at $0.67/person vaccinated or targeted (SD $0.94) and $0.10/dose delivered (SD $0.07). The average cost for vaccinator labor and incentive costs across 29 studies was $2.15/dose (SD $2.08). We identified 13 studies describing intervention costs for a vaccinator to know the location of a beneficiary, with an average cost of $19.69/person (SD $26.65), and six studies describing vaccinator travel costs, with an average cost of $0.07/dose (SD $0.03). Only eight of these studies described hard-to-reach populations for vaccination; two studies examined incremental costs per dose to reach hard-to-reach populations, which were 1.3-2 times higher than the regular costs. The incremental cost to train vaccinators was $0.02/dose, and incremental labor costs for targeting hard-to-reach populations were $0.16-$1.17/dose. CONCLUSION Additional comparative costing studies are needed to understand the potential differential costs for vaccinators reaching the vaccination sites that serve hard-to-reach populations. This will help immunization program planners and decision-makers better allocate resources to extend vaccination programs.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA; Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Tatenda T Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth Mitgang
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY, USA
| | - Patrick T Wedlock
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY, USA
| | - Colleen Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Hui-Han Chen
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sarah W Pallas
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Taiwo Abimbola
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Aaron Wallace
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Sarah M Bartsch
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY, USA
| | - Bruce Y Lee
- Public Health Informatics, Computational, and Operations Research (PHICOR), CUNY Graduate School of Public Health and Health Policy, New York City, NY, USA
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Saleem Z, Godman B, Azhar F, Kalungia AC, Fadare J, Opanga S, Markovic-Pekovic V, Hoxha I, Saeed A, Al-Gethamy M, Haseeb A, Salman M, Khan AA, Nadeem MU, Rehman IU, Qamar MU, Amir A, Ikram A, Hassali MA. Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications. Expert Rev Anti Infect Ther 2021; 20:71-93. [PMID: 34038294 DOI: 10.1080/14787210.2021.1935238] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.Areas covered: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.Expert opinion: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.
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Affiliation(s)
- Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK.,School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa.,School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town Malaysia
| | - Faiza Azhar
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | | | - Joseph Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University, Ado-Ekiti, Nigeria
| | - Sylvia Opanga
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Vanda Markovic-Pekovic
- Department of Social Pharmacy, Faculty of Medicine, University of Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Iris Hoxha
- Department of Pharmacy, Faculty of Medicine, University of Medicine Tirana, Albania
| | - Amna Saeed
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Manal Al-Gethamy
- Alnoor Specialist Hospital Makkah, Department of Infection Prevention & Control Program, Makkah, Kingdom of Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al Qura University, Makkah, Kingdom of Saudi Arabia
| | - Muhammad Salman
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Ayaz Ali Khan
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Muhammad Umer Nadeem
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Inaam Ur Rehman
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Muhammad Usman Qamar
- Department of Microbiology, Faculty of Life Sciences, Government College University Faisalabad, Faisalabad, Pakistan
| | - Afreenish Amir
- Department of Microbiology, National Institute of Health Islamabad, Pakistan
| | - Aamer Ikram
- Department of Microbiology, National Institute of Health Islamabad, Pakistan
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Ataullahjan A, Ahsan H, Soofi S, Habib MA, Bhutta ZA. Eradicating polio in Pakistan: a systematic review of programs and policies. Expert Rev Vaccines 2021; 20:661-678. [PMID: 33896306 DOI: 10.1080/14760584.2021.1915139] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Established in 1994, Pakistan's polio program demonstrated early success. However, despite over 120 supplementary immunization activities in the last decade, polio eradication efforts in Pakistan have been unable to achieve their objective of halting polio transmission. Variable governance, and inconsistent leadership and accountability have hindered the success of the polio program and the quality of the campaigns. Insecurity and terrorism has interrupted polio activities, and community fears and misbeliefs about polio vaccinations continue to persist.Areas covered: The article consists of a systematic review of the barriers and facilitators associated with the delivery of polio eradication activities in Pakistan. We also provide a comprehensive review of the policy and programmatic decisions made by the Pakistan Polio Programme since 1994. Searches were conducted on Embase and Medline databases and 25 gray literature sources.Expert opinion: Polio eradication efforts must be integrated with other preventive health services, particularly immunization services. Addressing the underlying causes of polio refusals including underdevelopment and social exclusion will help counteract resistance to polio vaccination. Achieving polio eradication will require building health systems that provide comprehensive community-centered care, and improving governance and systems of accountability.
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Affiliation(s)
- Anushka Ataullahjan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Hanaa Ahsan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Sajid Soofi
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muhammad Atif Habib
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.,Centre of Excellence in Women and Child Health, Aga Khan University South-Central Asia, East Africa & United Kingdom
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Kazi AM, Qazi SA, Khawaja S, Ahsan N, Ahmed RM, Sameen F, Khan Mughal MA, Saqib M, Ali S, Kaleemuddin H, Rauf Y, Raza M, Jamal S, Abbasi M, Stergioulas LK. An Artificial Intelligence-Based, Personalized Smartphone App to Improve Childhood Immunization Coverage and Timelines Among Children in Pakistan: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e22996. [PMID: 33274726 PMCID: PMC7748948 DOI: 10.2196/22996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/07/2020] [Accepted: 11/10/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The immunization uptake rates in Pakistan are much lower than desired. Major reasons include lack of awareness, parental forgetfulness regarding schedules, and misinformation regarding vaccines. In light of the COVID-19 pandemic and distancing measures, routine childhood immunization (RCI) coverage has been adversely affected, as caregivers avoid tertiary care hospitals or primary health centers. Innovative and cost-effective measures must be taken to understand and deal with the issue of low immunization rates. However, only a few smartphone-based interventions have been carried out in low- and middle-income countries (LMICs) to improve RCI. OBJECTIVE The primary objectives of this study are to evaluate whether a personalized mobile app can improve children's on-time visits at 10 and 14 weeks of age for RCI as compared with standard care and to determine whether an artificial intelligence model can be incorporated into the app. Secondary objectives are to determine the perceptions and attitudes of caregivers regarding childhood vaccinations and to understand the factors that might influence the effect of a mobile phone-based app on vaccination improvement. METHODS A mixed methods randomized controlled trial was designed with intervention and control arms. The study will be conducted at the Aga Khan University Hospital vaccination center. Caregivers of newborns or infants visiting the center for their children's 6-week vaccination will be recruited. The intervention arm will have access to a smartphone app with text, voice, video, and pictorial messages regarding RCI. This app will be developed based on the findings of the pretrial qualitative component of the study, in addition to no-show study findings, which will explore caregivers' perceptions about RCI and a mobile phone-based app in improving RCI coverage. RESULTS Pretrial qualitative in-depth interviews were conducted in February 2020. Enrollment of study participants for the randomized controlled trial is in process. Study exit interviews will be conducted at the 14-week immunization visits, provided the caregivers visit the immunization facility at that time, or over the phone when the children are 18 weeks of age. CONCLUSIONS This study will generate useful insights into the feasibility, acceptability, and usability of an Android-based smartphone app for improving RCI in Pakistan and in LMICs. TRIAL REGISTRATION ClinicalTrials.gov NCT04449107; https://clinicaltrials.gov/ct2/show/NCT04449107. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/22996.
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Affiliation(s)
- Abdul Momin Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Saad Ahmed Qazi
- Department of Electrical Engineering, NED University of Engineering and Technology, Karachi, Pakistan
- Neurocomputation Lab, National Centre of Artificial Intelligence, Karachi, Pakistan
| | - Sadori Khawaja
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Nazia Ahsan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rao Moueed Ahmed
- Department of Civil Engineering, NED University of Engineering and Technology, Karachi, Pakistan
| | - Fareeha Sameen
- Department of Civil Engineering, NED University of Engineering and Technology, Karachi, Pakistan
| | | | - Muhammad Saqib
- Department of Civil Engineering, NED University of Engineering and Technology, Karachi, Pakistan
| | - Sikander Ali
- Faculty of Electrical and Computer Engineering, NED University of Engineering and Technology, Karachi, Pakistan
| | - Hussain Kaleemuddin
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Yasir Rauf
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Mehreen Raza
- Pharmacy Services, Aga Khan University, Karachi, Pakistan
| | - Saima Jamal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Munir Abbasi
- Surrey Business School, University of Surrey, Guildford Surrey, United Kingdom
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Ozawa S, Yemeke TT, Evans DR, Pallas SE, Wallace AS, Lee BY. Defining hard-to-reach populations for vaccination. Vaccine 2019; 37:5525-5534. [PMID: 31400910 PMCID: PMC10414189 DOI: 10.1016/j.vaccine.2019.06.081] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/29/2022]
Abstract
Extending the benefits of vaccination to everyone who is eligible requires an understanding of which populations current vaccination efforts have struggled to reach. A clear definition of "hard-to-reach" populations - also known as high-risk or marginalized populations, or reaching the last mile - is essential for estimating the size of target groups, sharing lessons learned based on consistent definitions, and allocating resources appropriately. A literature review was conducted to determine what formal definitions of hard-to-reach populations exist and how they are being used, and to propose definitions to consider for future use. Overall, we found that (1) there is a need to distinguish populations that are hard to reach versus hard to vaccinate, and (2) the existing literature poorly defined these populations and clear criteria or thresholds for classifying them were missing. Based on this review, we propose that hard-to-reach populations be defined as those facing supply-side barriers to vaccination due to geography by distance or terrain, transient or nomadic movement, healthcare provider discrimination, lack of healthcare provider recommendations, inadequate vaccination systems, war and conflict, home births or other home-bound mobility limitations, or legal restrictions. Although multiple mechanisms may apply to the same population, supply-side barriers should be distinguished from demand-side barriers. Hard-to-vaccinate populations are defined as those who are reachable but difficult to vaccinate due to distrust, religious beliefs, lack of awareness of vaccine benefits and recommendations, poverty or low socioeconomic status, lack of time to access available vaccination services, or gender-based discrimination. Further work is needed to better define hard-to-reach populations and delineate them from populations that may be hard to vaccinate due to complex refusal reasons, improve measurement of the size and importance of their impact, and examine interventions related to overcoming barriers for each mechanism. This will enable policy makers, governments, donors, and the vaccine community to better plan interventions and allocate necessary resources to remove existing barriers to vaccination.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA; Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | - Tatenda T Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | | | - Sarah E Pallas
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Aaron S Wallace
- Global Immunization Division, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Bruce Y Lee
- Public Health Computational and Operations Research (PHICOR), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, MD, USA
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