Tackling Inequities in Immunization Outcomes in Urban Contexts

"Promoting community participation to understand the challenges of accessing immunization services and design more appropriate services is key to improving immunization coverage and equity in urban areas."

Rapid urbanisation over the next 50 years is expected to increase the burden on health services in urban settings. Many of the world's fastest growing megacities are in low- or middle-income countries (LMICs), where inequities - such as in immunisation coverage - can be stark. To understand the scope of this problem and how to address it, the Equity Reference Group for Immunisation (ERG), with support from PATH, conducted a literature review and 110 individual expert interviews to highlight new approaches and technologies for addressing immunisation inequity in urban contexts.

The ERG is concerned about 7 key aspects of inequities in urban health systems:

1. A lack of accurate, disaggregated data creates difficulty in identifying and tracking populations.
2. Cultural differences and discrimination can create social distance and disenfranchised communities, lead to a mistrust of the health system, and influence health care-seeking behaviour. For example, caregivers who recently resettled may lack social networks that would spur conversations on child health, and migrant women may lack health literacy if they do not understand local signage due to language barriers.
3. Quality of services and a lack of information impact access to immunisation services, especially for low-income, working caregivers.
4. There is a lack of political will to prioritise immunisation services for disenfranchised communities.
5. Residents of informal settlements may fear identification and prosecution through the sharing of health facility records with a public health department that is restricting or persecuting undocumented residents, and authorities may exclude those communities from service delivery.
6. Multiple stakeholders and a lack of effective partnerships, particularly with private-sector providers, reduce opportunities for data and information sharing, policy alignment, and convenient services for caregivers of unimmunised children.
7. Insecurity and violence in slums pose an increasing challenge for marginalised communities accessing health services, especially in Latin America.

To generate evidence and guidance on the challenges experienced in urban areas to inform programmatic changes, the Urban Immunization Working Group started in 2017 and, in 2018, published a toolkit - based on the 5 components of the Reaching Every District (RED) strategy (see Annex 4 for a summary). While the toolkit contains a comprehensive set of approaches, several key gaps in knowledge exist, in the ERG's estimation - for example, fast, low-cost, and tested solutions that empower marginalised populations and democratise access to services.

In light of identified gaps, the ERG investigated novel interventions or approaches, particularly from outside the immunisation sector, that could address challenges to achieving equity in urban settings. They focus on community-level policies and practices that can be implemented today, while acknowledging that national policy, governance, and financing influence the power communities hold. 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. The strategies examined include:

• Collecting timely and actionable data - For example, one study demonstrated the ability of mobile phone records to detect internal migration patterns in Rwanda. A challenge is aligning incentives and reaching agreement with the telecommunication company to access the data. Also, whilst new sources of data extend the ability to estimate population, collecting new data is not worthwhile unless the data are used and actionable. User-friendly dashboards and visualisations are necessary to inform the work of health workers at all levels of the health system.
• Increasing community engagement - Even when identified, unimmunised people may not seek health services, in part because of mistrust of the system or discrimination. Through collective action (e.g., community forums), communities can hold health systems accountable for service delivery, improving engagement and quality. Media campaigns that include community voices were suggested to the ERG as methods to address hesitancy and misinformation and encourage behaviour change to increase demand. Traditional routes (e.g., radio, television) or new formats like community-produced resources and social media have made for effective campaigns. Some studies note that information is not enough in informal settlements: Unless the caregiver has internalised the information on immunisation through robust discussion, often reinforced by social networks, health care-seeking behaviour is unlikely to change. The increasing prevalence of mobile phones, internet access, and social media provide another type of opportunity for community engagement in urban areas. However, over-reliance on these technologies can widen inequity based on gender, as women own mobile phones at a lower rate than men.
• Motivating health workers - The most commonly cited interventions were incentives (monetary and nonmonetary) and improved peer networks to promote the role of community health workers (CHWs) as change agents. One suggestion is to increase recognition of health workers by engaging them in the testing and implementation of programme changes through quality improvement teams. This model results in greater ownership of the process, empowers staff to make further changes, and enables task-shifting. Another idea to improve motivation included developing a virtual community of practice through social media or short messaging service (SMS). For example, health workers in Tanzania established a WhatsApp peer support group as part of the Better Immunization Data Initiative.
• Offering flexibility in services - For example, integration of immunisation and other health services would allow health workers to address missed opportunities during antenatal care and curative services. The Urban Health Resource Centre (UHRC) in India has adoped a holistic, community-based approach that supports the creation of women's groups and offers them training sessions not only on health issues but also on how to advocate for solutions to everyday challenges. UHRC outreach campaigns in slums and Urban Accredited Social Health Activists (ASHAs) play a key role in encouraging health care-seeking. Engaging men in questions about their children's immunisation may encourage them to participate in conversations about health.
• Building partnerships for greater impact - Partnerships are critical ways to improve service provision and community engagement. Creating nontraditional partnerships with new sectors and organisations, such as community groups, can extend the reach of existing programmes. Political leaders are also essential collaborators, especially when addressing the legal status of recent migrants living in informal settlements. And collaboration with employers is an opportunity to provide immunisation behaviour change communication or the social protections (e.g., approved time off) caregivers need to seek immunisation services.

The ERG recommendations (see the chart on pages 21-22) reflect the framework for action pictured in figure 4 on page 19. 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.

One takeaway from the report: "Overall, evidence demonstrates that the most effective tool in changing behavior towards improved immunization coverage is community-led information sessions and discussion. It is critical that the sessions allow for vigorous information exchange with caregivers, rather than short lectures at the facility level."