Household Cost-benefit Equations and Sustainable Universal Childhood Immunisation: A Randomised Cluster Controlled Trial in Sout

Published in BioMed Central (BMC)'s open access, peer-reviewed journal BMC Public Health (Vol. 5, No. 72), this 6-page study outlines and endorses the concept of using communication to open evidence-based dialogue that can increase community ownership of immunisation.

Specifically, the researchers - most of whom are affiliated with the Mexico-based Community Information and Epidemiological Technology/Centro de Investigación de Enfermedades Tropicales (CIET) - describe here a planned evidence-based intervention in Lasbela district in the south of Pakistan, where only 1 in every 10 children is immunised despite free immunisation offers by government health services. In an attempt to understand this challenge, the researchers observe that health care consumers make rational decisions about service use based largely on the costs and perceived benefits of health interventions - which can result in under-utilisation of public services like immunisation if household decision-makers are not properly informed about the cost-benefit equation.

The strategy being proposed here is that communication could be used to influence household decision-makers' cost-benefit assessments of immunisation - specifically, through efforts that rely not on one-way knowledge transfer (KT) but, rather, on more holistic KT strategies that take account of social and cultural influences such as gender and social inequalities. As noted here, impact studies of communication strategies to increase vaccination in the United States, Russia, and Mozambique have highlighted the effectiveness of involving multiple groups - families, communities, health practitioners and opinion makers, such as community and religious leaders - in these more holistic types of communication for immunisation approaches.

Specifically, the initiative detailed here involves 4 main objectives, and attendant strategies:

1. Identify the barriers and information imbalances that reduce childhood immunisation and increase understanding of the household cost-benefit equations underlying uptake of immunisation: In 32 communities representative of Lasbela district, 3344 households participated in a baseline survey on early child health. The researchers then carried out a behaviour change model adapted by CIET called CASCADA, an acronym which refers to: conscious knowledge about immunisation and its side effects, attitudes about childhood immunisation, social norms (what neighbours do) and positive or negative deviation from those norms, intentions to change or to vaccinate in the future, agency (expectancy of self-efficacy or collective efficacy), and discussion about immunisation, its benefits and side effects - followed by action (immunisation).
2. Formulate and implement 2-way KT based on household cost-benefit equations, compared
   with health information in reference (control) communities: In the 18 randomly selected intervention communities, the researchers will stimulate discussions on the household cost-benefit equation, as measured in the baseline, in an effort to take ordinary people's views about immunisation systematically into account. Having observed that mass media appeals need to be combined with interpersonal channels such as reminder systems and engagement through trusted sources - in short, addressing risks and benefits of vaccination in an understandable manner - researchers will conduct an analysis in order to estimate the impact of KT on changing beliefs and practices of decision-makers for children (i.e. immunisation uptake).
3. Measure the impact of 2-way KT on coverage and attitudes about immunisation: Following household interviews, communication strategies will be designed based on focus group discussions (FGDs) that last no more than 1 hour, are confidential, are led by a trained facilitator, and involve 8-12 participants. The reference (control) communities will also participate in the 3 annual follow-up surveys, feedback of the general survey results, and the usual health promotion activities relating to immunisation - but, crucially, this group will not participate in focused discussion on the household cost-benefit equations.
4. Develop an evidence-based and gendered systems approach to increasing equity in
   immunisation, one that is rooted in community knowledge and which is capable of building on local health protection cultures: Parallel to the community-based KT intervention, the team will work with the district authorities in Lasbela to build capacity to improve immunisation rates. This strategy is based on the premise that respectful dialogue with local health and political authorities about immunisation concepts, service delivery, effects and side effects in the communities is key in the process of demonstrating - by measuring and communicating - the effect on cost and benefit assessments.

This project aims to open up new horizons for KT as a 2-way communication strategy by implementing and then measuring the impact of this strategy in one particular context, with the idea that the improved understanding that may result could be applicable in many other countries/contexts.