Reasons related to non-vaccination and under-vaccination of children in low and middle income countries: Findings from a systematic review of the published literature, 1999-2009

US Centers for Disease Control and Prevention, Global Immunization Division, USA.
Vaccine (Impact Factor: 3.62). 09/2011; 29(46):8215-21. DOI: 10.1016/j.vaccine.2011.08.096
Source: PubMed


Despite increases in routine vaccination coverage during the past three decades, the percent of children completing the recommended vaccination schedule remains below expected targets in many low and middle income countries. In 2008, the World Health Organization Strategic Advisory Group of Experts on Immunization requested more information on the reasons that children were under-vaccinated (receiving at least one but not all recommended vaccinations) or not vaccinated in order to develop effective strategies and interventions to reach these children.
A systematic review of the peer-reviewed literature published from 1999 to 2009 was conducted to aggregate information on reasons and factors related to the under-vaccination and non-vaccination of children. A standardized form was used to abstract information from relevant articles identified from eight different medical, behavioural and social science literature databases.
Among 202 relevant articles, we abstracted 838 reasons associated with under-vaccination; 379 (45%) were related to immunization systems, 220 (26%) to family characteristics, 181 (22%) to parental attitudes and knowledge, and 58 (7%) to limitations in immunization-related communication and information. Of the 19 reasons abstracted from 11 identified articles describing the non-vaccinated child, 6 (32%) were related to immunization systems, 8 (42%) to parental attitudes and knowledge, 4 (21%) to family characteristics, and 1 (5%) to communication and information.
Multiple reasons for under-vaccination and non-vaccination were identified, indicating that a multi-faceted approach is needed to reach under-vaccinated and unvaccinated children. Immunization system issues can be addressed through improving outreach services, vaccine supply, and health worker training; however, under-vaccination and non-vaccination linked to parental attitudes and knowledge are more difficult to address and likely require local interventions.

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    • "Cost-effectiveness of immunization programs is well documented worldwide within developed and developing country settings [1] [2] [3] [4] [5]. Although strong steps have been taken globally to expand immunization coverage rates, the progress is not sufficient in many countries and several issues are still pending on the international agenda: how to identify and reach out to nonserved population? "
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    ABSTRACT: This paper identifies factors that affect the cost and performance of the routine immunization program in Moldova through an analysis of facility-based data collected as part of a multi-country costing and financing study of routine immunization (EPIC). A nationally representative sample of health care facilities (50) was selected through multi-stage, stratified random sampling. Data on inputs, unit prices and facility outputs were collected during October 3rd 2012-January 14th 2013 using a pre-tested structured questionnaire. Ordinary least square (OLS) regression analysis was performed to determine factors affecting facility outputs (number of doses administered and fully immunized children) and explaining variation in total facility costs. The study found that the number of working hours, vaccine wastage rates, and whether or not a doctor worked at a facility (among other factors) were positively and significantly associated with output levels. In addition, the level of output, price of inputs and share of the population with university education were significantly associated with higher facility costs. A 1% increase in fully immunized child would increase total cost by 0.7%. Few costing studies of primary health care services in developing countries evaluate the drivers of performance and cost. This exercise attempted to fill this knowledge gap and helped to identify organizational and managerial factors at a primary care district and national level that could be addressed by improved program management aimed at improved performance. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Vaccine 05/2015; 33S:A72-A78. DOI:10.1016/j.vaccine.2014.12.041 · 3.77 Impact Factor
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    • "Though the cumulative evidence is impressive, it offers a limited perspective. First, while the characteristics of unvaccinated children are likely to be different from those of undervaccinated children, primary studies have generally considered partially vaccinated and unvaccinated children together, and relatively few have focussed on unvaccinated children [10]. Second, previous studies limited their analysis mainly to individual- and household level-factors using fixed effects models [11], [12]. "
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    ABSTRACT: Background Children unreached by vaccination are at higher risk of poor health outcomes and India accounts for nearly a quarter of unvaccinated children worldwide. The objective of this study was to investigate compositional and contextual determinants of non-receipt of childhood vaccines in India using multilevel modelling. Methods and Findings We studied characteristics of unvaccinated children using the District Level Health and Facility Survey 3, a nationally representative probability sample containing 65 617 children aged 12–23 months from 34 Indian states and territories. We developed four-level Bayesian binomial regression models to examine the determinants of non-vaccination. The analysis considered two outcomes: completely unvaccinated (CUV) children who had not received any of the eight vaccine doses recommended by India’s Universal Immunization Programme, and children who had not received any dose from routine immunisation services (no RI). The no RI category includes CUV children and those who received only polio doses administered via mass campaigns. Overall, 4.83% (95% CI: 4.62–5.06) of children were CUV while 12.01% (11.68–12.35) had received no RI. Individual compositional factors strongly associated with CUV were: non-receipt of tetanus immunisation for mothers during pregnancy (OR = 3.65 [95% CrI: 3.30–4.02]), poorest household wealth index (OR = 2.44 [1.81–3.22] no maternal schooling (OR = 2.43 [1.41–4.05]) and no paternal schooling (OR = 1.83 [1.30–2.48]). In rural settings, the influence of maternal illiteracy disappeared whereas the role of household wealth index was reinforced. Factors associated with no RI were similar to those for CUV, but effect sizes for individual compositional factors were generally larger. Low maternal education was the strongest risk factor associated with no RI in all models. All multilevel models found significant variability at community, district, and state levels net of compositional factors. Conclusion Non-vaccination in India is strongly related to compositional characteristics and is geographically distinct. Tailored strategies are required to overcome current barriers to immunisation.
    PLoS ONE 09/2014; 9(9):e106528. DOI:10.1371/journal.pone.0106528 · 3.23 Impact Factor
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    • "Additionally, associations among the types of barriers were observed, including associations between service quality and parental factors, such as forgotten appointments. In this respect, our findings are consistent with a recent assessment of 202 studies on the epidemiology of unvaccinated and undervaccinated children in low- and middle-income countries that found factors associated with undervaccination to be complex and interrelated [13]. "
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    ABSTRACT: Background The Expanded Program on Immunization (EPI) in Colombia has made great advances since its inception in 1979; however, by 2010 vaccination coverage rates had been declining. In 2010, the EPI commissioned a nationwide study on practices on immunization, attitudes and knowledge, perceived service quality, and barriers to childhood immunization in order to tailor EPI communication strategies. Methods Colombia’s 32 geographical departments were divided into 10 regions. Interviewers from an independent polling company administered a survey to 4802 parents and guardians of children aged <5 years in these regions. To better assess barriers to vaccination, the study was designed to have 70% of participants who had children with incomplete vaccination schedules. Explanatory factorial, principal component, and cluster analyses were performed to place participants into a group (segment) representing the primary category of reasons respondents offered for not vaccinating their children. Types of barriers were then compared to other variables, such as service quality, communication preferences, and parental attitudes on vaccination. Results Although all respondents indicated that vaccines have health benefits, and 4738 (98.7%) possessed vaccination cards for their children, attitudes and knowledge were not always favorable to immunization. Six groups of immunization barriers were identified: 1) factors related to caregivers (24.4%), 2) vaccinators (19.7%), 3) health centers (18.0%), 4) the health system (13.4%), 5) concerns about adverse events (13.1%), and 6) cultural and religious beliefs (11.4%); groups 1, 5 and 6 together represented almost half (48.9%) of users, indicating problems related to the demand for vaccines as the primary barriers to immunization. Differences in demographics, communication preferences, and reported service quality were found among participants in the six groups and among participants in the 10 regions. Additionally, differences between how participants reported receiving information on vaccination and how they believed such information should be communicated were observed. Conclusions Better understanding immunization barriers and the users of the EPI can help tailor communication strategies to increase demand for immunization services. Results of the study have been used by Colombia’s EPI to inform the design of new communication strategies.
    BMC Public Health 06/2014; 14(1):669. DOI:10.1186/1471-2458-14-669 · 2.26 Impact Factor
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