Evaluating an Immunization Carpool Service for Women in Rural Areas for Facilitating Routine Childhood Immunizations in Pakistan - A Feasibility Study on Acceptability, Demand, and Implementation

"The women's carpool model showed a high acceptance among rural women, allowing them to overcome cultural restrictions, limited mobility, and safety concerns."

Pakistan is among the top 10 countries with the largest burden of unvaccinated children and significant disparities in coverage rates. Poor accessibility of immunisation services coupled with limited options for transportation and socio-cultural norms that hinder women's mobility are among the key factors contributing to poor immunisation coverage in rural areas. This study assessed the feasibility and acceptability of establishing a free-of-cost, women-only carpool service for immunisation in a rural setting (Shikarpur District, Sindh, Pakistan) and evaluated its preliminary impact on immunisation coverage and timeliness among children.

The feasibility study was conducted in four selected immunisation facilities with a lack of suitable public transportation options and low immunisation coverage: In 2020, the estimated full immunisation coverage rate among children less than 12 months in Shikarpur was 30%, less than half of the national coverage rate of 66%. The inclusion criteria for the study included children aged two years or below who were due for any vaccine. Coverage was analysed for all antigens administered as part of the routine immunisation schedule in Pakistan.

To begin, the researchers conducted visits within the catchment areas to explore locally available transport options that could feasibly be adapted for the intervention. They selected qingqis, a three-wheeler motorcycle with three forward-facing and three rear-facing passenger seats, as the immunisation carpool vehicles, since they were among the commonly used vehicles for commuting in the area. They engaged local transport providers to obtain six qingqis rented for the project duration. To distinguish them from other qingqis, they featured customised banners that provided information about the carpool services, the name of the nearest immunisation facility, and facility timings. Moreover, the researchers produced a jingle in the local language that was played on the carpool vehicles during their operational hours to notify the community about the arrival of carpool vehicles in their area.

Community mobilisation was carried out through awareness sessions delivered by study staff to the catchment population at their houses or by assembling residents of 2-3 houses in one place. The key purpose of these sessions was to advocate for and inform about the immunisation carpool services to community members, including males, to ensure their inclusion in health-related matters of their children and encourage female caregivers to utilise carpool services for attending immunisation facilities. Moreover, banners were displayed at frequently visited places such as mosques, health facilities, and neighbourhood shops, providing information about the newly introduced carpool services.

For the study, information on demographic indicators and service experience was collected. Child immunisation details were extracted using the government's provincial electronic immunisation registry to estimate immunisation coverage and timeliness.

Between January and October 2020, the six qingqis provided uninterrupted service and transported 2,422 women-child pairs, completing 4,691 immunisation visits. The majority of women reported that the carpool service improved accessibility (99.6%) by offering group travel (82.9%) and reducing their dependency on family members (93.4%). No complaints were reported by women on the conduct of drivers, and no unforeseen incidents with the vehicle or women were reported. Furthermore, no challenges were observed regarding any hindrances caused by male family members for women using the carpool service, highlighting its collective acceptability.

The study generated preliminary evidence of improved immunisation coverage (between 16% and 38%) and timeliness (between 4% and 18%) for various vaccines administered as part of routine immunisation schedule among participating and non-participating children who belonged to the same catchment sites. For example, there were significant increase in proportion for Bacillus Calmette-Guérin (BCG) coverage (38.1%; p < 0.001, confidence interval (CI): 32.8%, 43.4%) and measles-2 timeliness (18%; p < 0.001, CI: 13.3%, 22.4%).

Notably, timeliness for BCG and oral polio vaccine birth dose (OPV-0) was lower among participating children, indicating that these children were left behind and had not initiated their immunisation process and would likely have remained unreached by the health system if they had not utilised the carpool service. Per the researchers, these zero-dose (ZD) children were not even covered by the immunisation outreach teams that provide door-to-door vaccination services to children, showing caregivers' reluctance to vaccinate their children. The possible reasons for vaccine hesitancy could be fear of side effects such as post-vaccination fever and vaccine-related myths/misconceptions. Visiting immunisation facilities allows interaction with fellow women attending clinics for their child's vaccination, which may help in reducing their fears pertaining to vaccinations. Moreover, staff at primary health facilities can provide appropriate information and counseling to mothers. Hence, the socialisation opportunity provided to women through carpool intervention could help address the leading reasons for ZD status.

According to the researchers, key distinguishing factors of the intervention included:
 

• The service was designed primarily for women. Even when household attitudes and norms favour immunisation, by virtue of men controlling critical resources, women nevertheless depend on men to enable access to these services. The carpool intervention essentially overcame these key challenges by enabling local women to accompany each other safely and access immunisation services without depending on male family members. In addition, the inclusion of males in awareness sessions (>50% of participants in these sessions were males) helped sensitise them about the safety of carpool intervention, resulted in better penetration of the intervention in the community, and  possibly played a role in addressing the cultural norms that hinder female mobility.
• There was adaptation of locally available and culturally acceptable means of transportation. In contrast to interventions that involve adapting complex processes or relying on digital tools or vouchers, the carpool intervention was inherently simple in nature and relied almost exclusively on existing resources easily available in the community study setting. The qingchis leveraged for this study were already being used as ambulances in case of emergencies in rural settings in Pakistan.
• The carpool service introduced in this study provided free-of-cost services to women. In many countries, including Pakistan, routine vaccination programs are delivered through public health facilities that administer free vaccines to all children. Therefore, the main affordability barrier is traveling costs and the opportunity cost of taking time off from work to bring the child to the immunisation centre. This intervention essentially tackled both of these barriers.

Some lessons from the study to increase take-up of the service include including male family members in the awareness process, increasing community awareness for the intervention, maintaining service quality and ensuring reliability of dropoff and pick-up times, and encouraging women users to tell their peers about their positive experiences with the service.

In conclusion: "The study serves as baseline evidence for advocacy, policy analysis, and policy-making to improve healthcare delivery in rural areas of LMICs [low- and middle-income countries] by providing free or subsidized commuting options to women. Moreover, the women's carpool has shown preliminary evidence of improving overall immunization coverage and timeliness and covering zero-dose children. Women carpool services could increase access to immunization services, vaccine equity, and uptake while reducing urban-rural disparities."