A Holistic Strategy of Mother and Child Health Care to Improve the Coverage of Routine and Polio Immunization in Pakistan: Results from a Demonstration Project

"...findings support the assumption that polio vaccines can be well received if they are delivered as part of a package of health services, and this could be a better way to engage local communities, religious leaders, and other stakeholders rather than polio-specific programs."



In Pakistan, efforts to eradicate poliovirus and improve routine immunisation (RI) coverage rates present significant challenges. The history of these efforts shows that building trust and demand for polio vaccines requires great attention to effective communication and community mobilisation. For example, one approach has entailed reframing polio messages within the broader context of preventive health services for children (polio vaccines, RI, exclusive breastfeeding, hand washing, and diarrhoea management). The objective of this study is to assess the impact of an integrated strategy implemented between 2014 and 2016 to enhance community engagement and maternal and child health immunisation campaigns in 146 high-risk union councils (UCs) of 10 polio-endemic districts in Sindh, Khyber Pakhtunkhwa (KP), and Quetta block districts in Baluchistan, Pakistan.



Working in close coordination with the local government, World Health Organization (WHO), and United Nations Children's Fund (UNICEF) staff, the researchers used an approach based on community engagement and a human-centric design that considered common misperceptions and barriers related to maternal and child healthcare seeking - specifically, childhood immunisations. Polio immunisation was included in the context of RI, focusing on complete immunisations. This approach involved:

1. Actively engaging and mobilising the local community: Organisers developed information, education, and communication (IEC) materials (a pictorial booklet and counselling cards) to address different segments of the intended audience. Teams comprising 2 female and 2 male community mobilisers were recruited and trained to deliver the information in the IEC material. Each team covered 4 clusters and delivered key messages through individual sessions with parents and group sessions with male groups, female groups, and healthcare providers at the cluster level. Sessions with community and religious leaders, teachers, and other prominent persons were held at the UC level. Typically, 15 to 20 people attended the male and female group sessions, while 10 to 15 attended the other sessions. A limited number of sessions were held with healthcare providers and influencers at the introduction of the project, with a focus on the importance of RI and oral polio vaccine (OPV)/inactivated polio vaccine (IPV) administration.
2. Setting up maternal, newborn, and child health (MNCH) camps: Before the establishment of the 3-day camps, announcements were made at the community level, and invitation cards and information about health camps were distributed. Families were encouraged to visit these health camps, which generally started after the supplementary immunisation activities (SIAs) rounds, with the consensus of the polio emergency operating cell (EOC). The health camps offered MNCH services and RI plus IPV as needed. The aim was to vaccinate each child under the age of 5 years in the target areas. In each UC, 2 fixed and 2 mobile health camps were organised per round, and 6 rounds of health camps (one round per month) were organised in target areas to improve community access.

An independent team conducted surveys at 3 key points (baseline, midline, and endline) to evaluate immunisation coverage among children under the age of 5. The primary outcome measures for the study were coverage of OPV, IPV, and changes in the proportion of unvaccinated and fully vaccinated children. To select clusters and eligible households in each cluster, the researchers used a 30 × 15 cluster sampling technique. Multivariable associations between socio-demographic factors and changes in the proportion of fully vaccinated children at the UC level were assessed using hierarchical linear regression models.



A total of 256,946 children under the age of 5 (122,950 at baseline and 133,996 at endline) were enrolled in the study. Approximately 480,762 children aged under 5 were vaccinated with more than 200,000 IPV doses, while 16,539 females received antenatal care (ANC) services, with around 70% OPV coverage and 60% full immunisation. These figures represent an increase in all 3 study areas compared to the baseline.



The full immunisation rates were assessed on 3 levels of the framework: the distal, intermediate (access and environment), and proximal level (camp attendance and effectiveness).

• At the distal level, on multivariate analysis, among various indicators, family size was found to be a significant predictor of change in immunity in families with a family size of more than six members; their full immunisation was significantly better (β = 0.68; p = <0.0001). Bivariate analysis reflected that the likelihood of full immunisation coverage increased with decreased Pashto speaking (β = 0.1; p = 0.045).
• At the intermediate level, the likelihood of full immunisation decreased with the decrease in knowledge about vaccination (β = -0.38; p = 0.002), knowledge about polio vaccine (β = -0.25; p = 0.011), and knowledge about IPV (β = -0.06; p = 0.546). Perceived obstacles to vaccination were fear of adverse events (β = -0.4; p ≤ 0.0001) and lack of education (β = 0.23; p = 0.031), which were found to be significant in bivariate and multivariate analyses.
• At the proximal level, community mobilisation (β = 0.26; p = 0.008) and attendance at health camp (β = 0.21; p ≤ 0.0001) were found to enhance full immunisation coverage. On the other hand, the most prominent reason for not attending health camp included no need to attend the health camp as the child was not ill (β = -0.13; p = 0.008).

Thus, this evaluation demonstrated a substantial increase in the coverage of RI along with polio vaccines throughout the project. "Despite uncertain security conditions, population restrictions, and vaccine hesitancy, the favorable combined impact of community mobilization, and delivery of MNCH and immunization services through temporary MCH-focused health camps during SIAs was evident. Furthermore, this intervention was effective in increasing vaccine coverage and considered feasible and acceptable by the community....In contrast to the negative concerns regarding the uptake and administration of polio vaccines, the highest proportion of IPV coverage was seen in Baluchistan (73.8%), despite it being a traditional high-risk zone with a historically poor performance in terms of the polio program. This enhancement in OPV and IPV coverage is promising in achieving the threshold required for stopping poliovirus circulation."



However, the project had some challenges in its execution. For example, at times, the high demand for services at the health camps made it difficult for project staff to control the crowds that turned out. To address this issue, organisers involved community leaders and local community volunteers to help maintain order. The study is also limited by the fact that coverage estimates were largely based on family reports and doses administered at the campsite. This reliance on family reporting could introduce potential biases in the coverage estimates and is likely the only source of information in such conflict-affected insecure areas. Future approaches could also rely on vaccination records, paper or electronic.



In conclusion: "This study found that community mobilization and attendance at health camps significantly enhanced full immunization coverage. The findings highlight the importance of community engagement and targeted interventions in improving immunization coverage and addressing barriers to healthcare seeking."