Interventions For Improving Childhood Immunization Coverage In Low- And Middle-income Countries: A Cochrane Review Summary

Importance of childhood immunization

In the prevention of childhood diseases and mortality, immunization is an important pillar to improving child survival past 5 years of age (Strikas et al, 2015). This essay seeks to address the structured applicability of the Cochrane Review on the interventions of improving immunization coverage in children in Kenya. In the objectives, the essay will evaluate the effectiveness and efficiency of the interventions suggested in the systematic review by Oyo-Ita and colleagues and achieve a high childhood immunization coverage above the 80% mark set by the World Health Organization.  Because of the differences in the contexts, programs, policies and settings in different countries both economically, politically and socially, health support frameworks and structures in one health system or another might be feasible in the other (Adetifa, et al., 2018). Therefore, the interventions and strategies might seem effective from a readers’ perspective, the differences in health setting may result in a non-achieving interventions or policies. In simplifying the work of policy makers, such as health care providers, the government or non-governmental organizations, systematic reviews such as the Cochrane review summarize the evidence from studies conducted in different settings and therefore provide a standard point of application of the strategies and interventions, Mutua, Kimani-Murage, Ngomi, Mwaniki & Echoka (2016). However, the systematic review in most instances does not provide the salient features of the primary health settings where the studies were conducted. This therefore, warrants the review of the systematic review in such an essay, to determine the applicability of the interventions to the target country or healthcare setting for the policy makers before implementation (Awoyele, Pore, & Speakman, 2016). Hence, this essay will summarize for the policy makers, the answers to the questions concerning the interventions determined by research evidence to improve immunization coverage in Kenya and thus determine the efficacy of the strategies outlined in the Cochrane Review.

The immunization program in Kenya is regulated by the Kenya Extended Program on Immunization, an extension of the Extended program on Immunization(EPI) of the world health organization founded in the year 1974 to ensure, objectively, that all the children in the world and therefore applicable to Kenya are immunized fully (WHO, 2018) (Bangure, Chirundu, Gombe, Marufu, & Mandozana, 2015).  In the KEPI schedule, the following immunization vaccines are provided for, Mutua et al, 2016:

At birth or 1st clinical contact	6 weeks	10 weeks Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	14 weeks	9 months
Bacterium of Calmette Guerin (BCG)
Oral polio vaccine	Oral polio vaccine	Oral polio vaccine	Oral polio vaccine
	Pentavalent vaccine against: } Diphtheria } Pertussis } Tetanus } Hepatitis B } Haemophius Influenza Type b	Pentavalent vaccine against: } Diphtheria } Pertussis } Tetanus } Hepatitis B } Haemophius Influenza Type b	Pentavalent vaccine against: } Diphtheria } Pertussis } Tetanus } Hepatitis B } Haemophius Influenza Type b
				Measles.

• Over the years, institutions and stakeholders have worked in tandem to increase the coverage of immunization in Kenya. Intended to reach the at least 80% target coverage, Kenya still faces many challenges to reach and maintain that coverage percentage especially in rural and marginalized areas of the country such as Narok, Turkana, Nyanza and North-Eastern districts of the country(Awoyele, Pore, & Speakman, 2016).   Currently in Kenya, approximately 74% of the children aged between 12 to 24 months have fully been vaccinated (Elizabeth, George, Raphael, & Moses, 2015). However, this is just an average with the urban areas such as Nairobi registering high coverage proportions while low income countries such as Mandera, Marsabit, Nyando, Isiolo and Turkana registering values as low as 37% of the children population having reported to complete the full KEPI immunization program. Coverage by Province (Chepkemoi, Karanja & Kombich, 2013);
  1. Central 86%
  2. Rift valley 85%
  3. Eastern 84%
  4. Coast 76%
  5. Western 73%
  6. Nairobi 73%
  7. Nyanza 65%
  8. North Eastern 48%

The Kenya Extended program on Immunization intends to maintain the coverage above the recommended 80%, it faces challenges from within and without the system arising from the community, health providers, stakeholders, policy makers and politicians and ministry of health (Negussie, Kassahun, Assegid, & Hagan, 2015). The greatest challenge is that more than 56% of the Kenyan health care is spend by the non-governmental sector including private facilities, religious institutions and non-governmental organizations which do not have a clearly defined coordination mechanism between the institutions and the ministry of health hence unaccountability (Negussie, Kassahun, Assegid, & Hagan, 2015). Furthermore, parental illiteracy, low socioeconomic position, inaccessibility to health care and home delivery, unplanned large families and political influences played a major role in reducing the immunization coverage in the country (Adetifa at al., 2018). Moreover, the Kenyan community has a poor health seeking behavior towards treatment, with patients only considering sickness when the pain is too great to bear (Nelson, Wallace, Sodha, Daniels, & Dietz, 2016). This character makes the community not see the full need for immunization when the child is “healthy” and able to play unless complains of pain.  

Challenges in achieving high immunization coverage in Kenya

In the Cochrane review, the applied interventions in the research studies reviewed were applied n random control trials and compared to standard care. The interventions included those targeted at the recipients of health care, the community that is the parents, health care providers and an integrated immunization health care system to include the government, stakeholders and policy makers.

In the findings on improving child immunization by targeting the community through health education programs, the systematic review determined that in the target population of children less than 24 months old, there was tremendous improvement in the immunization cover for DPT₃ when the community was offered healthcare education on the importance and benefits of immunization to their children (Nelson, Wallace, Sodha, Daniels, & Dietz, 2016).  There was a moderate certainty, Chepkemoi, Karanja & Kombich, (2013) that the interventions provided would be efficacious in other health care settings of low income countries of Africa and Middle East Asia and the Caribbean.   

By offering facility based education on health care and immunization, with card reminders for next schedules, the Cochrane review determined that in a population of participants with children under the age of 6 years, the effect of the interventions would have a low certainty when applied to a different health setting (Adetifa, Karia, Mutuku, Bwanaali, Makumi, Wafula & Mataza,2018).  However, the research provides an indication for success effects in a health care setting since the intervention increased the number of immunized children per 1000 to a higher rate.

 Targeted towards the community and health care givers, incentives in terms of monetary benefits were given to increase the immunization coverage. This was compared against the standard care where no incentives were given, monetary or otherwise. The effect in the monetary incentives was very low in the certainty GRADE of the evidence (Nzioki, Ouma, Ombaka, & Onyango, 2017). This implied that monetary incentives provide some hint that there is a likely effect of the evidence to occur in a different health care setting however that the outcome might be substantially different is also very high.

Home visits were reviewed and compared to standard care. This intervention obtained a low grade for the working group grade of evidence meaning that although in a similar settings results would be positive, there is a significant chance that in a different setting the outcome would be deviated from the expected as suggested by the evidence in the systematic review, Lomondo & Okto, 2016.

In the review of the research conducting comparing the outcome when immunization outreach with incentives or without ere conducted to estimate the percentage coverage, a low Grade certainty of evidence was determined in both instances (Nelson, Wallace, Sodha, Daniels, & Dietz, 2016). The effects of immunization outreach would have some significant when applied to a health setting similar to the primary setting of study. However, the probability that the outcome would be opposite in a different health care setting is high.

To improve childhood immunization coverage, the researchers integrated immunization with other health services such treatment and prevention of malaria in Mali. The effect of the integration on the outcome in Mal was very commendable. However, a lo certainty of the evidence was obtained upon systematic review and analysis. This indicated that the probability that the outcome of the intervention in a different health setting would be substantially different was high.

Interventions suggested in the Cochrane Review

In the Cochrane review, substantially different as used implies that there might be a very large difference in the outcome of the intervention that it might affect the policy makers’ decisions to either implement it or not in their own health setting.

The systematic review captured studies conducted in low and middle income countries with three countries in Africa as Ghana, Zimbabwe and Mali. However, the studies in the systematic review were not conducted in the same setting as Kenya when compared in terms of healthcare provision, political and economic stability, literacy levels and socioeconomic position of the population.  In the systematic review, the results of the researches conducted are consistent across the countries with near similar health care settings, however, the low certainty of evidence of the interventions would therefore confer a substantial difference in the outcomes when applied in a different health setting such as Kenya (Nzioki, Ouma, Ombaka & Onyango, 2017). The specifications regarding the time periods, as found in the abstract and results sections of the systemic review, is consistent with the information and characteristic of the healthcare settings in which the primary researches were conducted.

Comparing the on-ground realities and constraints affecting healthcare in Kenya and the research countries, there are differences that might substantially affect the outcome of the interventions. Thus this would alter the applicability, feasibility and efficacy of the polies if they were to be implemented directly without considerations.  In the research countries, located in low middle income countries, the systematic review focuses on Ghana, Zimbabwe and Mali, African countries that might have a close relation to Kenya in terms of culture, political and economic structure to Kenya’s (Nzioki, Ouma, Ombaka, & Onyango, 2017). However, there are important differences that cannot be ignored before the implementation of the immunization interventions, Thorpe, VanderEnde, Peters, Bardin & Yount (2016). Primarily the main differences are political stability and influence, corruption and leadership, literacy levels and socioeconomic position of the citizens.  

The following table outlines the major differences noted in the different countries as compared to Kenya that would otherwise render the interventions inapplicable and therefore reduce efficacy and feasibly.

Ghana.	Zimbabwe	Mali	Kenya.
Politically stable, peaceful.	Presidential system with human rights violations	Politically unstable with recent coup attempts.	Politically divided into ethnic groups thus influence distribution of resources.
28 million Ghanaians.	12 million Zimbabweans.	18 million populations, with a large percent in rural areas.	48 million Kenyans, with a large marginalized population and ethnic groups.
Low poverty and dependency ratio.	High poverty index and dependency ratio.	A very high poverty index and dependency ratio	Poor wealth distribution among the citizens with a large percentage living below the poverty line.
Low illiteracy levels with one of the highest enrollment levels in Africa.	High illiteracy levels.	Lower illiteracy due to free and compulsive primary education.	High illiteracy levels with child labour and prostitution.
Advanced biotechnology and education system	Less advanced biotechnology and education system.	Poorly developed social and education systems.	No dynamic and well-structured government policy hence high illiteracy and school enrolment.

Due to the above differences on the ground in relation to the countries in which the studies were conducted, there would be a substantial difference in the certainty of outcome if the policies and interventions in the systematic review were to be implemented unaltered (Lakew, Bekele & Biadgilign, 2015). However, due to non-specific similarities in the countries, the certainty index would be medium, meaning the interventions would increase the immunization coverage but with a smaller percentage as compared to the systematic review findings. This implementation would therefore imply that more resources would be utilized in the attainment of the coverage percentage and maintaining that at the recommended 80% coverage (Masika, Atieli, & Were, 2016).

Difference in health setting between the different countries where the primary research and studies were conducted could result in substantial failure of the intervention strategies as outlined in the systematic review, Frommer & Rychetnik (2003).  The Kenyan health care setting comprises of a very advanced and dynamic private sector that delivers easy access health care to the Kenyans but intended to making profits (Bangure, Chirundu, Gombe, Marufu, & Mandozana, 2015). The main stakeholders are individuals such as doctors with private clinics and health facilities, companies with advanced and modern hospital such as the Aga Khan hospital that serves the rich and affluent in society and non-governmental organizations/ religious groups that run and manage health facilities such as the Tenwek Mission Hospital (Adetifa, et al., 2018). According to Wanjala, 2016, nearly 2 thirds of the poorest Kenyans seek medical care in the private health sector. The control of the sector is very poor with a poorly developed and mismanaged health infrastructure hence the private facilities are not answerable to the government but their management boards or individuals. This therefore, makes the health setting unmanaged by the national government under the ministry of health, the private facilities therefore though patent-focused, are objectively operating to earn more profits.  The healthcare system comprises of a 6 tier health system from a community facility run by community health workers, dispensaries run by nurses, health centers run by clinical officers, sub-county facilities run by a medical officer, country hospitals run and managed by a medical officer as the medical chief of staff and the highest teaching and referral hospitals run by consultants (Negussie, Kassahun, Assegid, & Hagan, 2015). Due to the low socioeconomic status with half the population living below the poverty line, poverty diseases such as malnutrition, pneumonia, malaria, HIV/AIDS, diarrheal diseases and sexually transmitted diseases burden the already strained health system due to the large population, limited resources due to corruption and ethnic profiling (Adetifa, et al., 2018). The table below therefore summarizes the important differences in the health settings of the study countries and Kenya.

Ghana	Mali	Zimbabwe.	Kenya
Most of the health care is provided by the government through the ministry of health	Depends on international organizations and foreign missionary aids for health care.	Poor health system due to lack of political goodwill.	Largely provided by the private sector
Universal health care system with a well-developed service delivery, human resource and man-power and public education.	Limited medical facilities and short supply of medicines.	Limited facilities and service delivery.	Poor controlled and integrated with the national health sector through ministry of health.
Endemic diseases such as cholera, tuberculosis, anthrax and malaria.	Poverty diseases, malnutrition and poor sanitation a burden to health care.	Poverty diseases.	Preventable infectious diseases of poverty still a huge burden
A well-structured women’s health policy focused on family planning, nutrition, reproductive health and child health care.	Poo maternal and child health care.	Child health is the country’s 4th millennium goal but poor resources allocation.	A structured but not well developed and supervised maternal and child health care.

Effectiveness and efficiency of interventions

Relative effectiveness is an important health concern. This is the extent to which a health intervention will do more harm than good when applied in a different setting as compared to an alternative intervention (Nelson, Wallace, Sodha, Daniels, & Dietz, 2016). How health effectiveness might differ across different health settings is poorly understood, however, there are factors and characteristics specific to each individual health setting as formulated by the national policies that would affect the effectiveness of the interventions applied (Nelson, Wallace, Sodha, Daniels & Dietz, 2016). Since the relative effectiveness of a particular intervention depends on the other health inputs in the health settings, the difference in the structure and inputs of one setting to the other influences the relative effectiveness of the intervention provided that the relative efficacy of the intervention is assumed to be constant (Bangure, Chirundu, Gombe, Marufu, & Mandozana, 2015). If the relative effectiveness of the intervention therefore remained constant, the baseline differences in the inputs of the health setting will determine the final absolute effects of the intervention applied.

In the systematic review, the assuming that the interventions have a constant relative effectiveness in the different health settings, the difference in the baseline conditions and input might yield different results and outcomes in immunization coverage in Kenya. Even when the relative effectiveness remained the same in the different settings, the baseline conditions of literacy, poverty index, privatization of the health sector, poor government control and inadequate universal health coverage will result in a poor outcome of the interventions postulated in the systematic review even if the relative effectiveness remained the same Graham, Logan, Harrison, Straus, Tetroe, Caswell & Robinson (2006).  The following table outlines the important baseline conditions that might result in different absolute effects of the interventions when the relative effectiveness remains the same (Bangure, Chirundu, Gombe, Marufu, & Mandozana, 2015).

Baseline condition  level	Category.	Conditions.
Patient/ community/ parental level.	Sociodemographic characteristics.	Socioeconomic position. Literacy and education level. Employment status. Accessibility of health care services. Health seeking behavior.
Provider level.	Provider characteristics.	Private/public status and integration financial, human and medical resources availability.
Health system setting level.	National/ regional policies and regulations.	Health care service delivery frameworks. Universal care and insurance cover. Legal framework. Funding and resource allocation.

Since some of the determinants and baseline conditions operate at different levels, the education and information quality of the patients, providers and stakeholders would influence the absolute outcome of the interventions.

The benefits of child hood immunization are directly proportional to the immunization coverage in a health setting and system. From the systematic review in the Cochrane review, many suitable, effective and feasible interventions can be applied in different contexts with some certainty percentage to yield absolute positive outcomes in the health setting different from the primary setting of study (Gibson et al., 2017). The options include community education interventions targeted at increasing the knowledge of the population of the benefits and risks of immunizations and therefore improve the rate of full immunization completion in children. Additionally, use of incentives with education programs target at patients and health provides to encourage immunization and completion of the whole EPI schedule is an option (Negussie, Kassahun, Assegid, & Hagan, 2015). Moreover, the different health sectors need be integrated together with the private and public sector merged to ensure preventive medicine is addressed primarily through programs such as immunization. The implementation of these options depends on the systematic review and assessment of evidence based research studies in different health settings and comparison with local health settings to determine the relative effectiveness of the interventions (Elizabeth, George, Raphael, & Moses, 2015).  The process of monitoring and evaluation of the implemented interventions should involve performance and result analysis over the period to ensure efficacy, effectiveness and feasibility which the goal of improving outcomes and the absolute impact.  

Applicability of interventions in different health systems

References

Adetifa, I. M. O., Karia, B., Mutuku, A., Bwanaali, T., Makumi, A., Wafula, J., & Mataza, C. (2018). Coverage and timeliness of vaccination and the validity of routine estimates: Insights from a Vaccine Registry in Kenya. bioRxiv, 427773.

Awoyele, T. E., Pore, M., & Speakman, S. (2016). Situational Awareness of Childhood Immunization in Kenya. Online Journal of Public Health Informatics, 8(1).

Bangure, D., Chirundu, D., Gombe, N., Marufu, T., Mandozana, G., Tshimanga, M., & Takundwa, L. (2015). Effectiveness of short message services reminder on childhood immunization programme in Kadoma, Zimbabwe-a randomized controlled trial, 2013. BMC Public Health, 15(1), 137.

Bowen S, Zwi AB (2005) Pathways to “Evidence-Informed” Policy and Practice: A Framework for Action. PLoS Med 2(7): e166. https://doi.org/10.1371/journal.pmed.0020166

Daley, M. F., Glanz, J. M., Newcomer, S. R., Jackson, M. L., Groom, H. C., Lugg, M. M., … & McNeil, M. M. (2017). Assessing misclassification of vaccination status: implications for studies of the safety of the childhood immunization schedule. Vaccine, 35(15), 1873-1878.

Elizabeth, K., George, K., Raphael, N., & Moses, E. (2015). Factors Influencing Low Immunization Coverage Among Children Between 12-23 Months in East Pokot, Baringo Country, Kenya. Int J Vaccines Vaccin, 1(2), 00012.

Frommer M & Rychetnik L (2003) ‘From Evidence-Based Medicine to Evidence-Based Public Health’ In V. Lin and B. Gibson (eds) Evidence-Based Health Policy: Problems and Possibilities Oxford: Oxford University Press, p56-69.

Gibson, D. G., Kagucia, E. W., Ochieng, B., Hariharan, N., Obor, D., Moulton, L. H., … & Feikin, D. R. (2016). The Mobile Solutions for Immunization (M-SIMU) Trial: a protocol for a cluster randomized controlled trial that assesses the impact of mobile phone delivered reminders and travel subsidies to improve childhood immunization coverage rates and timeliness in western Kenya. JMIR research protocols, 5(2).

Gibson, D. G., Ochieng, B., Kagucia, E. W., Were, J., Hayford, K., Moulton, L. H., … & Feikin, D. R. (2017). Mobile phone-delivered reminders and incentives to improve childhood immunisation coverage and timeliness in Kenya (M-SIMU): a cluster randomised controlled trial. The Lancet Global Health, 5(4), e428-e438.

Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. (2006) Lost in knowledge translation: time for a map? J Contin Educ Health Prof: 26(1):13-24.

MacDonald, N. E., Harmon, S., Dube, E., Steenbeek, A., Crowcroft, N., Opel, D. J., … & Butler, R. (2018). Mandatory infant & childhood immunization: Rationales, issues and knowledge gaps. Vaccine.

Masika, C. W., Atieli, H., & Were, T. (2016). Knowledge, Perceptions, and Practice of Nurses on Surveillance of Adverse Events following Childhood Immunization in Nairobi, Kenya. BioMed research international, 2016.

Mutua, M. K., Kimani-Murage, E., Ngomi, N., Ravn, H., Mwaniki, P., & Echoka, E. (2016). Fully immunized child: coverage, timing and sequencing of routine immunization in an urban poor settlement in Nairobi, Kenya. Tropical medicine and health, 44(1), 13.

Negussie, A., Kassahun, W., Assegid, S., & Hagan, A. K. (2015). Factors associated with incomplete childhood immunization in Arbegona district, southern Ethiopia: a case–control study. BMC Public Health, 16(1), 27.

Nelson, K. N., Wallace, A. S., Sodha, S. V., Daniels, D., & Dietz, V. (2016). Assessing strategies for increasing urban routine immunization coverage of childhood vaccines in low and middle-income countries: A systematic review of peer-reviewed literature. Vaccine, 34(46), 5495-5503.

Nzioki, J. M., Ouma, J., Ombaka, J. H., & Onyango, R. O. (2017). Community health worker interventions are key to optimal infant immunization coverage, evidence from a pretest-posttest experiment in Mwingi, Kenya. Pan African Medical Journal, 28(1).

Onsomu, E. O., Abuya, B. A., Okech, I. N., Moore, D., & Collins-McNeil, J. (2015). Maternal education and immunization status among children in Kenya. Maternal and child health journal, 19(8), 1724-1733.

Ozawa, S., Clark, S., Portnoy, A., Grewal, S., Brenzel, L., & Walker, D. G. (2016). Return on investment from childhood immunization in low-and middle-income countries, 2011–20. Health Affairs, 35(2), 199-207.

Strikas, R. A., Child, A. C. I. P., Group, A. I. W., & Advisory Committee on Immunization Practices. (2015). Advisory committee on immunization practices recommended immunization schedules for persons aged 0 through 18 years—United States, 2015. MMWR. Morbidity and mortality weekly report, 64(4), 93.

Thorpe, S., VanderEnde, K., Peters, C., Bardin, L., & Yount, K. M. (2016). The influence of women’s empowerment on child immunization coverage in low, lower-middle, and upper-middle income countries: A systematic review of the literature. Maternal and child health journal, 20(1), 172-186.

World Health Organization, & World Health Organization. Department of Immunization. (2015). Immunization in practice: A practical guide for health staff. World Health Organization.

Zhou, F., Shefer, A., Wenger, J., Messonnier, M., Wang, L. Y., Lopez, A., … & Rodewald, L. (2014). Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics, peds-2013.