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Impact of campaign-style delivery of routine vaccines: a quasi-experimental evaluation using routine health services data in India.

ABSTRACT: The world is not on track to achieve the goals for immunization coverage and equity described by the World Health Organization's Global Vaccine Action Plan. Many countries struggle to increase coverage of routine vaccination, and there is little evidence about how to do so effectively. In India in 2016, only 62% of children had received a full course of basic vaccines. In response, in 2017-18 the government implemented Intensified Mission Indradhanush (IMI), a nationwide effort to improve coverage and equity using a campaign-style strategy. Campaign-style approaches to routine vaccine delivery like IMI, sometimes called 'periodic intensification of routine immunization' (PIRI), are widely used, but there is little robust evidence on their effectiveness. We conducted a quasi-experimental evaluation of IMI using routine data on vaccine doses delivered, comparing districts participating and not participating in IMI. Our sample included all districts that could be merged with India's 2016 Demographic and Health Surveys data and had available data for the full study period. We used controlled interrupted time-series analysis to estimate the impact of IMI during the 4-month implementation period and in subsequent months. This method assumes that, if IMI had not occurred, vaccination trends would have changed in the same way in the participating and not participating districts. We found that, during implementation, IMI increased delivery of 13 infant vaccines, with a median effect of 10.6% (95% confidence interval 5.1% to 16.5%). We did not find evidence of a sustained effect during the 8 months after implementation ended. Over the 12 months from the beginning of implementation, we estimated reductions in the number of under-immunized children that were large but not statistically significant, ranging from 3.9% (-6.9% to 13.7%) to 35.7% (-7.5% to 77.4%) for different vaccines. The largest effects were for the first doses of vaccines against diphtheria-tetanus-pertussis and polio: IMI reached approximately one-third of children who would otherwise not have received these vaccines. This suggests that PIRI can be successful in increasing routine immunization coverage, particularly for early infant vaccines, but other approaches may be needed for sustained coverage improvements.

SUBMITTER: Clarke-Deelder E

PROVIDER: S-EPMC8128004 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectivesTo evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality.DesignGeographic regression discontinuity study.Setting572 villages in Karnataka, India.Participants31,476 households (22,796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28,633 households (21,767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme.InterventionA government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012.Main outcome measureOut-of-pocket expenditures, hospital use, and mortality.ResultsAmong households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, -0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (-5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality.ConclusionsInsuring poor households for efficacious but costly and underused health services significantly improves population health in India.

Project description:INTRODUCTION:Millions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme (ICDS) provide a range of health and nutrition services to pregnant women, children <6 years and their mothers. However, major gaps exist in ICDS service delivery. The government is currently strengthening ICDS through an mHealth intervention called Common Application Software (ICDS-CAS) installed on smart phones, with accompanying multilevel data dashboards. This system is intended to be a job aid for frontline workers, supervisors and managers, aims to ensure better service delivery and supervision, and enable real-time monitoring and data-based decision-making. However, there is little to no evidence on the effectiveness of such large-scale mHealth interventions integrated with public health programmes in resource-constrained settings on the service delivery and subsequent health and nutrition outcomes. METHODS AND ANALYSIS:This study uses a village-matched controlled design with repeated cross-sectional surveys to evaluate whether ICDS-CAS can enable more timely and appropriate services to pregnant women, children <12 months and their mothers, compared with the standard ICDS programme. The study will recruit approximately 1500 Anganwadi workers and 6000+ mother-child dyads from 400+ matched-pair villages in Bihar and Madhya Pradesh. The primary outcomes are the proportion of beneficiaries receiving (a) adequate number of home visits and (b) appropriate level of counselling by the Anganwadi workers. Secondary outcomes are related to improvements in other ICDS services, and knowledge and practices of the Anganwadi workers and beneficiaries. ETHICS AND DISSEMINATION:Ethical oversight is provided by the Committee for the Protection of Human Subjects at the University of California at Berkeley, and the Suraksha Independent Ethics Committee in India. The results will be published in peer-reviewed journals and analysis data will be made public. TRIAL REGISTRATION NUMBER:ISRCTN83902145.

Project description:We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda.We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention.Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. 'Bypassing' was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6.The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system.

Project description:BACKGROUND:Family planning (FP) needs among postpartum women in low- and middle-income countries remain largely unmet. Integrating FP with childhood immunisation services could partially reduce this unmet need by creating multiple opportunities for timely contact with FP services during the 12?months following childbirth. METHODS:A realist evaluation of an intervention integrating FP and childhood immunisation services in routine outreach clinics in two rural districts of Malawi was conducted. A Context-Mechanism-Outcome (CMO) framework was used to describe the drivers of the intervention. A detailed programme theory was developed based on the analysis of semi-structured interviews and focus group discussions with 50 stakeholders. RESULTS:A total of 9 core mechanisms were identified, which centred on constructs of access. Findings revealed that on the demand side, women were motivated to attend outreach clinics due to shorter travel distances; they felt confident they could access FP services and use contraceptive methods covertly if needed; and when supported by their husband, they were empowered to take up the use of contraceptive methods. On the supply side, providers were empowered through the training they received to provide integrated services; they were confident in their ability to provide essential services; and they were motivated by teamwork and by the recognition they received for their work. Additionally, some providers were found to be unwilling to walk long distances to reach remote clinics, which was seen to negatively affect the availability of services. CONCLUSIONS:The delivery of integrated FP and childhood immunisation services in the context of routine outreach clinics in rural Malawi was seen to trigger mechanisms of accessibility and to improve the acceptability and availability of FP services. However, further research is needed to understand how the integration of these services in a routine outreach clinic setting may affect other dimensions of accessibility, including the approachability, appropriateness and affordability of services.

Project description:BackgroundAccredited Social Health Activists (ASHA) are community health workers responsible for improving the health status of people by facilitating their access to healthcare services. The life skills of ASHA are known to be effective in negotiating behaviour change in the community; however, there has been a meagre focus towards improving them. Considering this gap, we adopted a comprehensive training program, known as Personal Advancement and Career Enhancement (P.A.C.E.), to empower ASHAs on life skills and financial literacy. The present study intends to assess the training program in two districts of Uttar Pradesh, India, by examining changes in knowledge, perceptions, and practices of ASHAs about life skills and financial literacy.MethodsWe conducted a quasi-experimental, non-randomized, controlled study with pre-and post-test assessments. Data were collected on socio-demographic characteristics, knowledge, and practices related to life skills (communication skills, self-confidence, problem-solving and decision-making skills, time and stress management skills) and financial literacy. Additionally, change perceptions on gender-, life skills-, and savings-related practices at the personal, community, and workplace levels were assessed in the intervention group. Factor analysis was performed to obtain the change patterns by assessing the degree to which the four life skills, financial literacy, and change perceptions on practices were correlated. A general linear regression model was performed to assess associations among change pattern scores and socio-demographic variables.ResultsWe analyzed the data of 171 ASHAs (intervention group:86 and control group:85). There was a significant improvement in the average post-test scores of all the life skills and financial literacy in the intervention group (p < 0.001). Three distinct change patterns were found post-training in the intervention group. Factor 1 (high loadings for change perceptions on practices) was positively associated with ASHAs aged 38 and above and with experience of ≤12 years. On the contrary, the change in financial literacy and self-confidence scores was common among ASHAs with more than 12 years of experience.ConclusionsThe P.A.C.E training program was found effective in improving the life skills and financial literacy of ASHAs in India.

Project description:BACKGROUND:Malnutrition is a major public health problem in India, especially among urban poor children. The objective of the study was to determine the effectiveness of a culturally appropriate nutrition educational intervention that can be delivered through health services and digitized child undernutrition tracking module for health workers to improve complementary feeding of infants of age six months to 12 months in Chandigarh, North India, to prevent malnutrition in infants. METHODS:A quasi-experimental study was conducted in a non-randomized intervention (Burail) and control area (Maloya) among a vulnerable population in Chandigarh, North India. The mother-infant dyads (MIDs) in the intervention group(n = 202) received culturally appropriate nutrition educational intervention, were supported individually by trained health workers in infant feeding and followed up for six months. Health workers were monitored through a digitized tracking module. The MIDs in the control group (n = 202) received routine care under the national health program. The mean (±S.D.) age of infants in the intervention and control group was 5.4 (±0.8) months and 5.5 (±0.7) months, respectively. The data was collected using a pre-tested semi-structured questionnaire and anthropometry of infants at baseline and end line. The primary outcome was a mean change in weight. The effectiveness of the intervention was measured by conducting the difference in difference (DID) analysis in mean change in weight between intervention and control group. RESULT:At baseline, the mean (±S.D.) weight of infants was 6.6(±0.64) kg and 6.6 (±0.52) kg in the intervention and control group. The mean (±S.D.) length of infants was 64.3 (±2.0) cm in the intervention group and 65.1 (±1.7) cm in the control group. Out of 404, 190 and 191 MIDs in the intervention and control group completed the study, respectively. A significantly higher number of infants in the intervention group were started on complementary feeding at six months of age (72.6% versus45.5%, p<0.01) and received foods having thick consistency (82.1% versus 41.9%, p<-0.01). There was significant weight gain in intervention group infants (DID means = 0.27 kg, p<0.01) and length gain (DID means = 0.9 cm, p<0.01) from the baseline. Also, there was significant decline in the proportion of undernourished (10% versus18.8%, OR = 0.47, p = 0.01) and wasted infants (7.3% versus15.7%, OR = 0.42, p = 0.01) in the intervention group. CONCLUSION:Community-based nutrition educational intervention delivered through the routine health services and digitized tracking of malnourished children can effectively improve the complementary feeding and growth of children six months to one year among vulnerable populations.

Project description:OBJECTIVES:In Emilia-Romagna, the Human Papillomavirus (HPV) vaccination campaign started in 2008 offering free vaccines for 1996 and 1997 cohorts. Systematic active invitation was implemented for the 1997 cohort. Our study aimed at measuring the impact of the active invitation campaign on HPV vaccine coverage and on coverage inequalities in 11-year-old girls. Second, we evaluated the effect of the HPV vaccination campaign on participation in cervical cancer screening by mothers of target girls. METHODS:We collected information on vaccination status for girls residing in Reggio Emilia in 2008 and mothers' screening history, before and after the 2008 vaccination campaign. Log-binomial regression models were performed to estimate Relative Risk (RR) and 95% confidence intervals (CIs) of being vaccinated as regarded citizenship, siblings, mothers' education, marital status and screening history, stratified by birth cohort. We also calculated RR of receiving a Pap test after the vaccination campaign as regarded education, daughter's cohort and mothers' decision to have their daughter vaccinated. Interaction between education and cohort in mothers overdue for Pap testing was calculated. RESULTS:Vaccination coverage was 46.3% for the uninvited cohort (1046/2260) and 77.9% for the invited cohort (1798/2307). In the uninvited cohort, daughters' vaccination showed association with mothers' education (8 to 11 years of education vs. graduated mothers, RR 1.61 95%?CI 1.14-2.28), citizenship (foreigners vs. Italians, RR 0.45 95%?CI 0.37-0.56) and screening history (regular vs. non-participant; RR 1.72 95%?CI 1.26-2.36). In the invited cohort, only a slight association with screening history persisted (regular vs. non-participant; RR 1.20 95%?CI 1.04-1.40). Highly educated under-screened mothers of the invited cohort showed a higher probability of receiving a Pap test after the vaccination campaign period (RR 1.27 95%?CI 1.04-1.56) compared with those not invited, CONCLUSION: Active invitation could increase overall HPV immunisation coverage and reduce socio-demographic inequalities and the association with mothers' screening participation.

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Impact of campaign-style delivery of routine vaccines: a quasi-experimental evaluation using routine health services data in India.

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