A Scoping Review on Integrated Health Campaigns for Immunization in Low- and Middle-Income Countries

"An integrated approach in immunization service delivery was found to successfully increase coverage using limited resources and finances, even in remote regions, as well as increasing community acceptance, reaching a specific target population, and increasing the impact of the given intervention."

Routine immunisation has a history of integration with other programmes, including Vitamin A supplementation, deworming, and insecticide-treated net (ITN) distribution in low- and middle-income countries (LMICs). Integrated health campaigns (IHCs) involve sharing, collaboration, and/or coordination of campaign components to improve the efficiency and effectiveness of multiple campaigns or allow simultaneous or co-delivery of two or more health interventions - one of which is immunisation - at the point of service delivery. This scoping review of literature from LMICs across the world summarised a collection of common strategies adopted or approaches towards implementation of IHCs in immunisation.

The team used three search engines (PubMed, Scopus, and Google Scholar) to identify peer-reviewed journal articles, as well as select institutional websites for grey literature publications. Full-text articles using any study design and across any time frame were included. The search was conducted over two weeks in July 2021 and updated in August 2022. Data were extracted following a predefined matrix, analysed deductively, and presented in a narrative synthesis. Thirty articles (20 academic and 10 grey) were included in the final review.

Across the board, the articles reviewed showed that the integration of campaigns has a positive impact on the coverage and/or effectiveness of vaccination campaigns. The common strategies were: using resources efficiently in remote locations; using national immunisation days to maximise impact; focusing on specific age groups by selecting intervention sites that are frequented by that age group; integrating programmes that already share common elements; and increasing community involvement, oftentimes contributing to the greater good of the intervention.

One of the mechanisms behind increased coverage is that integration allows healthcare workers to develop stronger trust and rapport with the community when they offer multiple services, including services that already have high acceptance within the community. Services that have low acceptance and trust in the community, when coupled with services that are already widely accepted, can increase coverage for the former. For example, as one study included in the review indicates, when maternal, newborn, and child health (MNCH) services were integrated with the less accepted child polio vaccination in conflict-affected and polio-endemic areas of Pakistan, the coverage and uptake of the oral polio vaccine (OPV) increased by 8.5%.

The most common facilitator of successful implementation mentioned by the included documents was the establishment of community ownership. IHC implementation is most promising in a community where health workers have established rapport system, trustworthy relationships, and a voice advocating their communities during an immunisation campaign. There are some effective strategies for responding effectively to community needs. In hard-to-reach communities, it is important to establish that the integrated programme is closing the gap between healthcare seekers and providers. Preexisting infrastructure such as healthcare programnes or various outreach programmes were identified as a key factor leading to the successful implementation of integrated health care in several LMICs. When the priority is diverse and involves different age groups, the best method of implementation was using a mix of health posts, such as schools, health facilities, and community vaccination posts.

The documents also described common barriers to effective integration. In general, they can be divided between issues related to the costs of integration and issues related to the management of human resources. For example, successful implementation of any integration programme requires the training of field staff to deliver multiple products or services simultaneously. In the case of programmes that have the same delivery method, workers must be trained separately for practices such as needle safety and communicating with the local community.

Generally, IHCs that can involve the community are more likely to last. A common goal for IHCs is to improve the coverage of a novel or stigmatised programme. This was most often done through integration with a nationwide immunisation campaign, a complementary programme, or a more socially accepted programme.

Despite major efforts by the governments in many countries to integrate campaigns, the researchers suspect that these efforts are not always reflected in academic articles. In the case of Bangladesh, for example, the number of grey articles surpasses the number of scholarly articles (7 to 1) on the same topic, and likely applies to other countries as well. LMICs, especially those with poor representation among the included documents of this study, bear closer examination in future studies, as it is evident that there is a large gap between the availability of scientific publications and the actual practice of IHCs.