The Drum Beat 838 - Toward Equity: Accessing and Engaging the Hard to Reach with Vaccination

• 1.Why Reaching Zero-Dose Children Holds the Key to Achieving the Sustainable Development Goals
  by Dan Hogan and Anuradha Gupta 
• The Immunization Agenda 2030 and the supporting Gavi 2021-2025 Strategy have ambitious targets to reduce the number of zero-dose children by 25% by 2025 and 50% by 2030 as compared to 2019 levels. However, studies have confirmed that zero-dose children and their families face multiple barriers to obtaining immunisation, and their presence in a community is often an indicator of compounded inequities. The Identify-Reach-Monitor-Measure-Advocate (IRMMA) framework offers a way to develop strategies to reach zero-dose children and missed communities. IRMMA involves diving deeper into subnational- and community-level inequities and identifying where unvaccinated children live and what barriers to immunisation they face. Tailored strategies appropriate for the local context then need to be designed and operationalised. [Mar 2323] 
   
• 2.Zero- or Missed-dose Children in Nigeria: Contributing Factors and Interventions to Overcome Immunization Service Delivery Challenges
  by Kurayi Mahachi, Joss Kessels, Kofi Boateng, et al. 
• Globally, more 22.7 million children are estimated to be zero- or missed-dose, of which an estimated 3.1 million reside in Nigeria. This scoping review of 127 papers aims to summarise all identified risk factors and interventions specific to zero- or missed-dose children in Nigeria. The most common vaccine studied was polio. To cite only one example: Training volunteer community mobilisers, traditional and religious leaders (e.g., traditional barbers), schoolteachers, and other community leaders to advocate for vaccination was found to have improved vaccination acceptance and uptake, particularly in traditional Muslim societies. [Aug 2022] 
   
• 3.Zero-Dose Childhood Vaccination Status in Rural Democratic Republic of Congo: Quantifying the Relative Impact of Geographic Accessibility and Attitudes toward Vaccination
  by Branly Kilola Mbunga, Patrick Y. Liu, Freddy Bangelesa, et al. 
• This study found that caregiver attitudes toward childhood vaccination, a proxy for intent to vaccinate, is a many-fold stronger predictor of non-vaccination than geographic accessibility in rural Democratic Republic of the Congo (DRC). [Jun 2024] 
   
• 4.Interventions to Vaccinate Zero-Dose Children: A Narrative Review and Synthesis
  by Erin A. Ingle, Priyanka Shrestha, Aparna Seth, et al. 
• Key informants working on last-mile delivery efforts for vaccination stressed that community involvement and participation are essential to reinforcing efforts to reach zero-dose children. Co-creating interventions with community assets such as informants, influential members, and survivors of VPD (e.g., polio survivors) enhances ownership and strengthens trust in vaccination services. However, this review highlights that the barriers to reaching zero-dose children are multifaceted and nuanced to each setting; therefore, no one intervention is enough. [Oct 2023] 
   
• 5.Assessing Vaccination Delivery Strategies for Zero-Dose and Under-Immunized Children in the Fragile Context of Somalia
  by Ahmed Said Bile, Mohamed A. Ali-Salad, Amina J. Mahmoud, et al. 
• Somalia is one of 20 countries in the world with the highest numbers of zero-dose children. Despite increasing awareness of this problem, study participants discussed the government's lack of clear strategies and plans to address it. They stressed the importance of knowledge about power structures in the community and the selection of individuals with such knowledge and good standing in the community to be social mobilisers. One community member said, "I think it would send a powerful signal of support if the top political, clan and religious leaders were seen taking their children to health facilities for immunization, not just a minister cutting ribbon or putting vaccine drops into a child's mouth for the start of immunization campaign." [Feb 2024] 
   

• 6.Public Health and Armed Conflict: Immunization in Times of Systemic Disruptions
  by Gudrun Østby, Olga Shemyakina, Andreas Forø Tollefsen, et al. 
• Vaccination programmes can be highly politicised and subjected to major security constraints in war zones, reducing their effectiveness. Careful planning and policy design specific to conflict environments is needed in the face of deep mistrust. The polio eradication campaign in the DRC in 1997 is a successful case in point in this regard. The United States Agency for International Development used back-door channels to develop relationships with rebel leaders and persuaded them that vaccination would be welcomed by parents, carried no costs, and was supported by the international health community. [Nov 2021] 
   
• 7.Expanding Polio Surveillance Reach beyond Vaccination Reach in Borno State, Nigeria: The Contribution of Community Informants from Insecure Areas Engaged to Conduct Polio Surveillance in Security Compromised Areas, 2018-2019
  by Abede Momoh Mohammed, Audu Musa, Sume Gerald Etapelong, et al. 
• Conflict and insecurity limiting access to populations have emerged as significant obstacles to polio eradication. This article demonstrates how the engagement of community informants from insecure areas to conduct acute flaccid paralysis surveillance in security-challenged settlements of Borno state, northeastern Nigeria, contributed to the expansion of polio surveillance reach. [May 2023] 
   
• See also:
  Reaching People in Fragile and Conflict-Affected Settings with Immunization Services
   

• 8.Ensuring the Integration of Refugees and Migrants in Immunization Policies, Planning and Service Delivery Globally
  One of the communication-related elements of this World Health Organization (WHO) review is a discussion of the unique barriers refugees and migrants may face in accessing vaccines. These barriers are individual-level barriers (e.g., trust, cultural, religious, social norms, and beliefs), logistical barriers, information and communication barriers, and administrative, policy, and financial barriers. For example, greater access to polio immunisation services for migrants in the WHO African Region, particularly those in hard-to-access border areas and seasonal migration routes, is needed. To support countries fully integrating refugees and migrants into national immunisation plans, and to increase access to routine vaccines, the report outlines areas for policy consideration. [Jul 2022] 
   
• 9.Perceived Barriers of Migrants and Refugees to Vaccinate Their Children against Measles and Polio: A Study in Iran
  by Amir Nasiri, Hossein Farshidi, Farshid Rezaei, et al. 
• Iran is at risk of a polio reemergence as it accommodates approximately 2.5 million Afghan refugees, while neighbouring countries Afghanistan and Pakistan continue to experience incidents of wild poliovirus (WPV) cases. This cross-sectional study involved 1,067 parents who had not vaccinated their children against polio and measles or had delayed receiving any dose until the age of 15. Results indicate low knowledge, unfavourable attitudes, communication challenges, lack of participation in vaccination programmes, and problems related to migration and refugee status. [Dec 2023] 
   
• 10.Key Considerations: Drivers Influencing Vaccination-related Behaviours Among Ukrainian Refugees in Poland
  by Erica Richardson 
• Efforts to ensure good access to vaccination services in Poland for child refugees from Ukraine and to provide tailored health promotion activities for caregivers have intensified since Russia invaded Ukraine in February 2022. This Social Science in Humanitarian Action Platform (SSHAP) brief draws on ongoing research by the United Nations Children's Fund that highlights how refugees' uncertain longer-term plans limit their vaccination uptake. According to SSHAP, messaging around vaccination should acknowledge this uncertainty and emphasise the importance of their children receiving routine vaccinations in Poland while waiting to determine their next move (if any), highlighting the social benefits vaccination entails. [2022] 
   
• 11.Planning and Implementing a Targeted Polio Vaccination Campaign for Somali Mobile Populations in Northeastern Kenya based on Migration and Settlement Patterns
  by Bonnie Harvey, Warren Dalal, Farah Amin, et al. 
• The movement and temporary settlement of under-vaccinated mobile Somali populations near and among under-vaccinated ethnic Somali communities in Kenya creates a situation where transmission of poliovirus among children is highly likely. Considering these risks, this project conducted a polio vaccination campaign reaching ethnic Somali children living in mobile populations under the age of 5 years in Garissa County, Kenya. By outlining the experience of planning and conducting the campaign, this paper provides an example of using community-based data collectors and local knowledge to adapt public health programming to the local context. [Oct 2022] 
   
• 12.Non-COVID-19 Vaccine Hesitancy among Migrant Populations Worldwide: A Scoping Review of the Literature, 2000-2020
  by Akhenaten Siankam Tankwanchi, Anelisa Jaca, Asiphe M Ndlambe, et al. 
• There is growing concern about the understudied phenomenon of anti-vaccine sentiments among migrant populations. Motivated by the belief that monitoring migrants' vaccination-related concerns can inform needed interventions to support vaccine acceptance, these researchers undertook a scoping review of the literature on vaccine hesitancy in migrant populations. One finding: "A social-ecological approach is...imperative in framing multilevel interventions to address under-immunization and health disparities in migrant communities..." [Jun 2022] 
   

• Eradicating Polio in Humanitarian and Crisis Contexts: The Drum Beat 811 [May 18 2022]
  
   

• 13.Parental Perceptions, Attitudes, and Beliefs Regarding Vaccination of Children Aged 0-5 Years: A Qualitative Study of Hill-tribe Communities, Thailand
  by Katemanee Moonpanane, Jintana Thepsaw, Khanittha Pitchalard, and Eva Purkey 
• Semi-structured interviews of 74 hill-tribe parents in Thailand highlighted that providing effective communication and education, as well as raising public awareness through campaigns by trusted healthcare providers and community leaders, could reduce vaccine hesitancy at the community level by helping limit the spread of rumours and distrust. The parents also supported leveraging direct personal contact or door-to-door campaigns, using village health volunteers to promote immunisation in children, and broadcasting vaccine information in specific languages. Training healthcare providers to provide culturally appropriate, non-stigmatising care to hill-tribe people is also recommended. [Jul 2023] 
   
• 14.Improving the Timeliness and Completeness of Childhood Vaccination through Color-coded Bracelets: A Pilot Study among Fulani Tribe Populations in Nigeria
  by Inuwa Barau Yau, Mahmud Zubair Mustapha, Eric Nwaze, et al. 
• About 60% of the population in Bauchi State, Nigeria, are Fulanis, a traditionally nomadic ethnic group with particularly low rates of vaccination coverage due to high mobility, low education levels, and cultural reasons. This controlled pilot intervention trial sought to: (i) investigate the feasibility of a colour-coded bracelet intervention amongst the ethnic Fulani population; (ii) assess and compare vaccination completeness and timeliness in the intervention and control populations; and (iii) study the feasibility and the effects of adding peer-to-peer mobilisers (PPM) for vaccination scale up. In short: "This study has demonstrated the feasibility of a composite intervention (bracelets & PPM) to increase the completeness and timeliness of childhood immunization and provided preliminary evidence for its efficacy amongst Fulani populations in Nigeria." [May 2023] 
   
• See also:
  Immunization among Tribal Population in India: A Need Assessment Report
   

• 15.Rethinking Strategies to Address Inequity in Immunization Services towards Achieving Universal Immunization Coverage (UIC) in Karachi, Pakistan
  by Iqbal Hossain, Tariq Masood, Akram Sultan, et al. 
• Due to the presence of many unimmunised and under-immunised children in Karachi, this Pakistani city experiences frequent outbreaks of measles, and WPV continues to circulate there. Reasons for low immunisation coverage include lack of demand and trust among people for immunisation services and lack of governance and accountability in a fragmented health management structure, among others. This paper highlights the process the Sindh Government, in collaboration with partners, undertook to address inequity in urban immunisation services in Karachi. The strategy was developed through was a stepwise process, with multiple layers of stakeholders' input and feedback informing co-creation of evidence-based interventions, such as engaging local traditional and religious leaders as messengers. [Oct 2021] 
   
• 16."I'll Take Them Another Day": A Qualitative Study Exploring the Socio-behavioral Complexities of Childhood Vaccination in Urban Poor Settlements
  by Judy Gichuki, Ben Ngoye, and Francis Wafula 
• This study explored the behavioural and social factors influencing childhood vaccination uptake in urban informal settlements in Nairobi, Kenya. Such settlements are characterised by highly dense residential spaces marked by overcrowding, limited access to essential services, and inadequate infrastructure. The study's conceptual framework is the Theory of Planned Behavior, and it finds that various social, behavioural, cultural, and contextual factors influence caregiver vaccination decisions in the urban economically poor setting under investigation. For example, gender-related barriers were an important social factor influencing timely childhood vaccination uptake. Interventions are also needed to minimise missed vaccinations due to caregivers' fear of being judged or stigmatised by healthcare providers or peers. [May 2024] 
   
• 17.Coverage and Drivers to Reaching the Last Child With Vaccination in Urban Settings: A Mixed-Methods Study in Kampala, Uganda
  by Carol Kamya, Faith Namugaya, Charles Opio, et al. 
• Challenges in the coverage and equity of vaccination persist in Kampala, Uganda, where 60% of the population resides in slum areas. This study sought to determine vaccine coverage among children aged 12-36 months living in Kampala and to understand demand-side drivers of vaccination coverage, with the goal of informing efforts to reach the last child. Notably, the Uganda National Expanded Program on Immunization uses a uniform communication strategy in rural and urban areas that overlooks the uniqueness of Kampala, including the existence of different subpopulations and the availability of a broad spectrum of media. The findings suggest the need for continuous health education efforts that are tailored to the complexities of urban settings characterised by mobile and diverse populations, busy parents, and a lack of formal addresses. [Aug 2022] 
   
• 18.Improving Timeliness and Completion of Infant Vaccination among Infants in Nigerian Urban Slums through Older Women's Participation
  by Folusho Mubowale Balogun, Eniola Adetola Bamgboye, and Abimbola Ellen Akindolire 
• Nigerian urban slums have a high population of infants with suboptimal vaccination. Older women traditionally play supervisory roles in infant care in Nigeria, but their influence is untapped in infant vaccination. This randomised experimental community study sought to determine if training of older women (35 years and above) in urban slum communities in Ibadan, Southwest Nigeria, and involving them in infant vaccination would improve infant vaccination timeliness and completion. Infants in the intervention group (67.9%) significantly had both timely and complete vaccinations compared with those in the control group (36.6%). [Sep 2022] 
   
• 19.Improving Equity in Urban Immunization in Low- and Middle-Income Countries: A Qualitative Document Review
  by Rachel Victoria Belt, Shakil Abdullah, and Sandra Mounier-Jack 
• 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. The findings indicate that challenges to immunisation equity in the urban context could be addressed through 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. [Jul 2023] 
   
• 20.Urban Immunization: A Tool Kit for Those Planning to Address Inequitable Immunization Coverage in the Urban Context
  Organised according to the 5 components of the Reaching Every District strategy, this toolkit outlines the tools and methods available to adapt other approaches to the urban disadvantaged setting, with links throughout to more detailed instructions. It was developed by the Urban Immunization Working Group, which coordinates efforts by immunisation partners to create awareness about inequities in urban areas and support development of strategies aimed at improving immunisation outcomes in those areas, especially slum environments. [Sep 2018] 
   

• 21.Oral and Inactivated Polio Vaccine Coverage and Determinants of Coverage Inequality Among the Most At-Risk Populations in Ethiopia
  by Samson Gebremedhin, Fisseha Shiferie, Dawit A. Tsegaye, et al. 
• A major threat to the Global Polio Eradication Initiative (GPEI) is the inability of endemic (i.e., Afghanistan and Pakistan) and outbreak-prone (e.g., Ethiopia) countries to sustain high vaccination coverage within all at-risk populations. Inequality in vaccination coverage is likely the reflection of both supply-side and demand-side factors. This study measured the coverage with inactivated poliovirus and third dose of oral polio vaccine and identified determinants of coverage inequality in the most at-risk populations in Ethiopia. Low paternal education, dissatisfaction with vaccination service, fear of vaccine side effects, female-headed households, and employed and less empowered mothers were risk factors. The researchers suggest that, to keep pace with the GPEI, Ethiopia needs to take actions such as integrating immunisation with other services to reduce missed opportunities. [Sep 2023] 
   
• 22.Using Geographic Information System to Track Children and Optimize Immunization Coverage and Equity in Karachi, Pakistan
  by Muhammad Siddique, Sundus Iftikhar, Vijay Kumar Dharma, et al. 
• This study conducted a geospatial analysis using provincial electronic immunisation registry data from Sindh province, Pakistan, to explore the geographic and temporal trends of immunisation coverage in Karachi city from 2018 to 2020. Per the researchers, the findings "emphasize the importance of geospatial analysis for revealing coverage rates at a sub-national level that could be masked when analyzing at the aggregate level. This is essential from an equity perspective..." [Apr 2023] 
   
• 23.Mission Indradhanush and Intensified Mission Indradhanush - Success Story of India's Universal Immunization Program and the Role of Mann Ki Baat in Bridging the Immunization Gap
  by Veena Dhawan, Ashish B. Chakraborty, Suhas Dhandore, et al. 
• This article explores the Government of India's push to address low childhood immunisation coverage through Mission Indradhanush (MI), which was launched in December 2014, and Intensified Mission Indradhanush (IMI), which was launched in October 2017. One of the distinctive approaches of MI was its emphasis on achieving equity by prioritising high-risk populations residing in traditionally underserved areas with low immunisation coverage. To reach children in these areas, a customised, evidence-based, and community-centric service delivery strategy was developed. The researchers suggest that advocacy of MI/IMI by the prime minister himself was pivotal. [Sep 2023] 
   
• 24.Advancing Immunization Coverage and Equity: A Structured Synthesis of Pro-Equity Strategies in 61 Gavi-Supported Countries
  by Vesela Ivanova, A. S. M. Shahabuddin, Alyssa Sharkey, and Mira Johri 
• Health inequities are significant drivers of gaps in immunisation coverage and challenges in reaching the most under-served communities in low- and middle-income countries. To identify country approaches to reach underimmunised and zero-dose children, these researchers undertook a structured synthesis of pro-equity strategies across 61 countries receiving programmatic support from Gavi, the Vaccine Alliance. Findings have been incorporated into a learning tool and searchable database of pro-equity strategies, which can serve as a resource and a guide to other countries who want to improve their immunisation coverage and equity. [Jan 2023] 
   

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