Improving Equity in Urban Immunization in Low- and Middle-Income Countries: A Qualitative Document Review

"As the world continues to urbanize, particularly in low- and middle-income countries, understanding the barriers and effective interventions to improve urban immunization equity is critical to achieving both Immunization Agenda 2030 targets and the Sustainable Development Goals."

Large numbers of zero-dose and under-immunised children reside in urban areas. The aim of this research is to improve understanding of urban immunisation equity through a qualitative review of mixed-method studies, urban immunisation strategies, and funding proposals across more than 70 urban areas developed between 2016 and 2020, supported by Gavi, the Vaccine Alliance. These research studies and strategies created a body of evidence regarding the barriers to vaccination in urban settings and potential interventions relevant to low- and middle-income countries (LMICs) with a focus on the vaccination of urban economically poor, populations of concern (e.g., migrants, refugees, internally displaced persons (IDPs), and homeless people), and residents of informal settlements.

The researchers identified 70 documents as part of the review and categorised results across the following thematic areas, drawing information from results in more than 21 countries:

• Social determinants of health:
  • Inequities included availability and proximity to service, discrimination, and security. Table 3 in the paper summarises the populations of concern and their associated barriers from the review.
  • Solutions aimed to tailor delivery and demand strategies to reach marginalised urban residents through community engagement and improved forecasting of vaccines to populations of concern. Recommendations included in country diagnostics and strategy reports are summarised in Table 4, including mobile and outreach strategies (market, street, places of worship), improved training of health workers on interpersonal interaction and information sharing, and tracking of migrant families to avoid loss to follow-up.
• Immunisation service delivery:
  • Service-delivery barriers facing urban communities related to the provision, distribution, and quality of the major inputs of immunisation services; moreover, there were significant governance issues between government ministries and private providers. A summary of common challenges across these areas is provided in Table 5.
  • The aims of solutions to improve health planning in urban areas included the improved collection and use of data, improved vaccine forecasting, enhanced political commitment, and financing for human resources and service delivery. The strategies identified the need to engage private healthcare providers, as there are more private providers in urban areas. The recommendations and proposed interventions for country strategies are available in Table 7.
• Quality of services:
  • The main demand-side barriers in urban areas ranged from lack of information - poor communication on the importance of vaccination, location, and timing of sessions - to stronger deterrents, including misinformation and poor treatment by health workers. For example, in Sierra Leone, mothers and caregivers reported being hesitant to return to health facilities for fear of being "chastised, rebuked or insulted" if they brought the children late back to vaccination. In some settings, there was a refusal of care to populations of concern such as migrants. However, there are also constraints in resources available to health workers and incongruence of legislation and professional norms and ethics in provision of service to migrants. Further, information on the demographics of beneficiaries for tailored communications, attention to child-friendly services, and models of community mobilisation were largely absent from programme plans and diagnostics.
  • Recommendations and proposed strategies ranged from healthcare worker interpersonal training to the hiring of outreach workers from marginalised populations to improve engagement. Efforts to tailor the service-delivery model to working and busy caregivers included interventions such as a dedicated vaccination line and after-hours vaccination. The use of mobile phone networks to share information and vaccination reminders was proposed in more than seven countries. Child-friendly improvements to clinics was a common intervention to improve the quality of care and immunisation experience. The recommendations and proposed interventions for country strategies are available in Table 8.

As the researchers note in discussing the findings, challenges to immunization equity in the urban context largely link to appropriate health planning and the design of inclusive and accessible health services for populations of concern and working caregivers. Leveraging multisectoral approaches in urban contexts could help improve overall service delivery and quality.

A research agenda based on the gaps identified in the review and input from the urban immunisation working group is presented in Table 9. For instance:

• Additional gender research is needed to include complex issues such as working parents.
• The efficacy and impact of the interventions proposed in this analysis remain a key research gap.
• The issue of cost barriers (e.g., for transport, for immunisation cards) was present across contexts and represents a significant future area of research.
• The development of models for the engagement of the private sector could benefit from a mapping and further analysis of existing contractual and operating arrangements, across countries.

In conclusion: "Populations of concern such as migrants, refugees, residents of informal settlements and the urban poor face barriers to accessing care which include poor availability and quality of service. Example solutions proposed to these challenges include tailored delivery strategies, improved use of digital data collection and child-friendly services. More research is required on the efficacy of the proposed interventions identified and on gender-specific dynamics in urban poor areas affecting equitable immunization coverage."