Tackling Inequities in Immunization Outcomes in Remote Rural Contexts

"Change agents at all levels must embrace equity-driven programming - from global donors to frontline health workers."

The senior experts in global health who make up the Equity Reference Group for Immunisation (ERG) contend that understanding the challenges and opportunities of immunisation for remote rural populations is key to improving immunisation equity. To that end, with support from PATH, members of the ERG conducted a literature review and 110 individual expert interviews to comprehend challenges to reaching equitable immunisation coverage and to identify the change agents and interventions with the potential to address these challenges. In this report, they outline what they see as promising, imaginative approaches at the community level.

The ERG explains that equitable delivery of immunisation services in rural settings is impacted in several ways. There are logistical issues, such as the high marginal cost of reaching remote rural populations, relative to other environments, and the difficulty of reaching these areas with vaccines at the right time due to the geographic remoteness. In addition, there are some communication-related challenges, including:

• Within remote rural contexts, the intersectionality of identities (such as gender, education, ethnicity/caste, religion, disability) shapes inequity of immunisation outcomes. For instance, limited education around disability contributes to greater stigma from community members and health providers, and poor infrastructure leads to increased challenges in accessing health facilities.
• Retention and motivation of personnel is impeded by resource-limited environments in rural areas. For instance, frontline health workers, who are predominantly women, may face sexual harassment or violence during their work. While male health workers do not face these same challenges, cultural challenges in some contexts may prevent caregivers from seeking health services from a male provider.
• Remote rural populations have limited socio-political power, which limits access to health institutions and health services. For instance, at an individual level, women lacking health literacy may have a weaker capacity to negotiate the health system, and people from ethnic minorities or indigenous populations may have linguistic differences from health workers. These and other power asymmetries result in limited accountability of the health systems to caregivers.
• Weak data and information use on remote rural populations limit the attention and effort focused on these areas. According to the ERG, good data systems remain the best way to identify vaccination inequities and require consistent support and maintenance.

Reaching Every District (RED) is the predominant approach used to address these challenges. (Annex 4 details the activities of RED and successes and challenges observed in implementation during the last decade.) The ERG reviews its components, including: (i) planning and management of resources; (ii) conducting supportive supervision; (iii) reaching all eligible populations; (iv) building community partnerships; and (v) monitoring and using data for action. The change agents who implement RED are: caregivers; civil society and community organisations (who may organise outreach and provide caregivers with information); community and religious leaders (who disseminate information and set community norms); health committees (which involve the community); community health workers; district-level health officers; national policymakers; and global donors.

According to the ERG, new and burgeoning interventions undertaken by these change agents may strengthen and extend the implementation of RED (which, they say, needs to be evaluated for the impact on vaccination equity). The report identifies multiple possible interventions, with ideas categorised with different icons as having been tried but needing to be either further strengthened or new and needing to be explored. Among the strategies examined:

• Collecting timely and actionable data through: satellite imagery and geographic information system (GIS) mapping combined with micro-census, integrated data systems, electronic immunisation registries (EHRs), and survey adaptations.
• Motivating health workers - For example, given the relative isolation of rural posts, peer support and connection are particularly important for providing learning, accountability, and support. Short messaging service (SMS, or text messaging) peer networks, particularly using WhatsApp, are increasingly popular.
• Increasing community engagement through, for example:
  • Individual patient feedback (e.g., SMS feedback systems);
  • Community forums to increase community monitoring and advocacy for health system quality;
  • Participatory planning approaches (ideally, engaging members across all strata of the community); and
  • Incentives to consumers (e.g., an Immunity Charm bracelet gifted at birth, with subsequent charms and beads are added to the bracelet as the immunisation series is completed).
• Communicating social behaviour change - Given the lower literacy and low health literacy levels in remote rural areas, the ERG identified several non-print methods to effectively engage caregivers:
  • Interactive education and communication - For instance, in Pakistan, polio campaigns have organised forums for discussion with female doctors, religious figures, female vaccinators, and women who have recently vaccinated their children. The increased penetration of mobile technologies and social networks has also allowed more dynamic communication of health information.
  • Non-print information, education, and communication (IEC) - Radio shows and community-developed videos can to promote health literacy and engage rural communities, regardless of education level.
• Integrating programmes - For example, in Ethiopia, there was pilot integration with nutrition and agricultural services, with a national cooperation platform guiding co-delivery by health and agricultural extension workers.

The ERG recommendations (see the chart on pages 25-27) reflect the framework for action pictured in figure 5 on page 23. They seek to identify (1) the problem (challenges) being addressed; (2) the innovative interventions necessary to reduce inequity; and (3) the change agents that can act. The ERG recommendations are categorised in 3 ways: (1) Act now. Evidence exists to support the idea, but with minimal implementation. (2) Continue doing. Interventions that are working well and should persist. (3) Test before acting. Interventions that require further study to assess and test value.

Annex 2 features 4 country case studies, which were selected due to the unique challenges these countries face in addressing urban-rural coverage differentials. These countries serve as examples of how innovative interventions can be applied to a context to help reach rural populations.