Inequalities in Ownership and Availability of Home-Based Vaccination Records in 82 Low- and Middle-Income Countries

"...aim is to better understand the spectrum of HBR [home-based record] status to inform how to improve their ownership, which could translate in increased demand for immunisation, better timeliness of vaccination and - at the health systems level - improved monitoring and measurement of vaccination status."

Home-based records (HBRs) are widely used for recording health information, including child immunisations. These printed documents/cards serve as a documentation tool that allows parents and health services to track the immunisation status of a child and to support compliance with vaccination schedules. They have also been seen as contributing to the right to access information and supporting global efforts for people-centred care by fostering communication between health workers and women, parents, and caregivers. However, substantial inequalities in child immunisation coverage have been widely documented in low- and middle-income countries (LMICs). The factors affecting HBR ownership in LMICs are likely the same as those affecting immunisation coverage. This article describes a study of levels and inequalities in HBR ownership in LMICs using data from national surveys conducted since 2010.

The researchers used data from national household surveys (Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS)) from 82 LMICs. They then classified 465,060 children aged 6-35 months into four categories: HBR seen by the interviewer; mother/caregiver never had an HBR; mother/caregiver had an HBR that was lost; and mother/caregiver reportedly has an HBR that was not seen by the interviewer. Inequalities according to age, sex, household wealth, maternal education, antenatal care, and birth in an institutional setting were studied, as were associations between HBR ownership and vaccine coverage. Pooled analyses were carried out using country weights based on child populations.

An HBR was seen for 67.8% (95% confidence interval (CI) 67.4% to 68.2%) of the children; 9.2% (95% CI 9.0% to 9.4%) no longer had an HBR; 12.8% (95% CI 12.5% to 13.0%) reportedly had an HBR that was not seen; and 10.2% (95% CI 9.9% to 10.5%) had never received one. The lowest percentages of HBRs seen were in Kiribati (22.1%), the Democratic Republic of Congo (24.5%), Central African Republic (24.7%), Chad (27.9%), and Mauritania (35.5%). The proportions of HBRs seen declined with age and were inversely associated with household wealth and maternal schooling. Antenatal care and giving birth in an institutional setting were positively associated with ownership. There were no differences between boys and girls. When an HBR was seen, higher immunisation coverage and lower vaccine dropout rates were observed, but the direction of this association remains unclear.

The availability of HBRs for inspection is dependent on several prerequisites. First, HBRs must be available at national level, and then in the health facility. Next, the caregiver must receive it from a health worker usually during or before the first immunisation encounter and bring the record back to the facility when every new vaccine is administered. The record must be properly stored and looked after a while in the household. For measurement purposes, during the household survey, the interviewer must request and wait to inspect the HBR to transcribe it. The HBR must also be readable, and the interviewer must correctly transcribe vaccine dates or vaccination check marks. The increasing complexity of immunisation schedules, the diverse range of HBRs in circulation, and the varying quality of their completion are making it increasingly challenging to record, read and transcribe information from HBRs.

The researchers point out that, while digitalisation may reduce the proportion of lost or misplaced HBRs, this strategy will only be effective where equitable and widespread internet access exists.

In short, the study found that "HBR coverage levels were remarkably low in many LMICs, particularly among children from the poorest families and those whose mothers had low schooling. Contact with antenatal and delivery care was associated with higher HBR coverage. Interventions are urgently needed to ensure that all children are issued HBRs, and to promote proper storage of such cards by families."