Door-to-door canvassing for immunization program acceleration in Mozambique: achievements and costs

The Expanded Program on Immunization has made remarkable progress in raising coverage in developing countries. Countries have been urged to accelerate their programs, especially in urban areas. In Mozambique, as part of program acceleration, volunteers from grassroots organizations conducted door-to-door canvassing for the Program. Concurrently, the availability of immunization was increased in health centers and in outreach visits. By 1987, over 90 percent coverage for all vaccines was achieved in the capital, Maputo; two other cities doubled their immunization coverage to over 50 percent fully immunized children, and rural areas of the pilot province achieved 60 percent coverage. Immunization costs were estimated in one city as $6.9 (U.S. dollars) per fully vaccinated child. Door-to-door canvassing accounted for more than 40 percent of personnel costs, and may have diverted attention from the quality of service in the health centers. In this article we outline the achievements and costs of door-to-door canvassing and discuss other strategies to raise coverage. The analysis of the need to balance the mobilization of demand with the capacity to respond is relevant to other countries in their efforts to develop sustainable immunization services.     

中国不同地区产妇住院分娩率与新生儿乙型肝炎疫苗接种率分析

目的分析新生儿乙型肝炎(乙肝)疫苗(HepB)接种率与产妇住院分娩率之间的关系,指导HepB预防接种工作。方法将2003年国家卫生服务调查的产妇住院分娩数据与2005年全国常规免疫接种报告的新生儿HepB接种数据进行配比分析。结果城市产妇住院分娩率高于农村,城市新生儿HepB接种率高于农村。在农村,产妇住院分娩率越高,新生儿HepB接种率越高,新生儿HepB接种率和产妇住院分娩率关系密切。结论为了提高新生儿HepB接种率,必须大力提倡产妇住院分娩,保证在医院出生的新生儿及时接种HepB;对在家出生的新生儿应采取特殊策略,保证及时接种HepB。     

Assessment of factors associated with complete immunization coverage in children aged 12-23 months: a cross-sectional study in Nouna district,Burkina Faso

Background

The Expanded Program on Immunization (EPI) is still in need of improvement. In Burkina Faso in 2003, for example, the Nouna health district had an immunization coverage rate of 31.5%, compared to the national rate of 52%. This study identifies specific factors associated with immunization status in Nouna health district in order to advance improved intervention strategies in this district and in those with similar environmental and social contexts.

Methods

A cross-sectional study was undertaken in 41 rural communities and one semi-urban area (urban in the text). Data on 476 children aged 12 to 23 months were analyzed from a representative sample of 489, drawn from the Nouna Health Research Centre's Demographic Surveillance System (DSS) database. The vaccination history of these children was examined. The relationships between their immunization status and social, economic and various contextual variables associated with their parents and households were assessed using Chi square test, Pearson correlation and logistic regression.

Results

The total immunization coverage was 50.2% (CI, 45.71; 54.69). Parental knowledge of the preventive value of immunization was positively related to complete immunization status (p = 0.03) in rural areas. Children of parents who reported a perception of communication problems surrounding immunization had a lower immunization coverage rate (p < 0.001). No distance related difference exists in terms of complete immunization coverage within villages and between villages outside the site of the health centres. Children of non-educated fathers in rural areas have higher rates of complete immunization coverage than those in the urban area (p = 0.028). Good communication about immunization and the importance of availability of immunization booklets, as well as economic and religious factors appear to positively affect children's immunization status.

Conclusion

Vaccination sites in remote areas are intended to provide a greater opportunity for children to access vaccination services. These efforts, however, are often hampered by the poor economic conditions of households and insufficient communication and knowledge regarding immunization issues. While comprehensive communication may improve understanding about immunization, it is necessary that local interventions also take into account religious specificities and critical economic periods. Particular approaches that take into consideration these distinctions need to be applied in both rural and urban settings.

Abstract in French

See the full article online for a translation of this abstract in French.

     

An evaluation of lot quality assurance sampling to monitor and improve immunization coverage

Quality assurance sampling techniques with small samples offer a method of monitoring performance of health services in small health areas, and of identifying areas with poor performance in which remedial actions need to be targetted. Lot Quality Assurance Sampling methods were used to assess the coverage resulting from three immunization campaigns in rural and urban areas in the mountains of Peru. Application of these methods in 12 health areas with populations of 538 to 15 780 by Ministry of Health personnel proved feasible and could be used to identify areas with poorer vaccination coverage. Further discussion about possible reasons for poor coverage led to corrective actions in these health areas and an improvement in overall coverage from 78% to 88% in a three-month period. These quality assurance methods are a useful supervisory tool to improve health programme performance.     

Factors influencing the performance of routine immunization in urban areas: A comparative case study of two cities in Cameroon: Douala and Yaoundé

Urban areas are often omitted from investigations on immunization because the published literature tends to focus on rural settings. The two largest cities in Cameroon – Douala and Yaoundé – are the main drivers of the high number of unvaccinated children in Cameroon. The objective of our study was to identify the factors influencing vaccine incompleteness in Douala and Yaoundé in children (12–23 months of age).We conducted a community-based cross-sectional study using concomitant mixed methods (qualitative and quantitative) with an explanatory aim. The study was conducted in three health districts in each city between March and April 2016.The number of nonvaccinated and incompletely vaccinated children was higher in Yaoundé (3.1% and 40.3%, respectively) than in Douala (0.7% and 10.1%, respectively). The most frequent reason for nonvaccination was related to the parent/guardian not knowing the consequences of not being vaccinated and lack of money. According to the explanatory model, nonvaccination in both cities was associated with the following issues: (1) perceived high visibility of the health district office in terms of vaccination, (2) the shortage of health personnel in immunization centers, (3) attending a private health facility, (4) average or poor behavior of health personnel at immunization centers, and (5) poor knowledge of vaccine-preventable diseases.This mixed-methods study illustrates how inadequacies of the health district framework within urban areas are fueling poor performance of routine immunization in Cameroon. Further research should inform the development of community-centered vaccination services that are most needed, especially in rapidly urbanizing sub-Saharan Africa.     

Expanding immunization coverage in rural India: A review of evidence for the role of community health workers

Poor routine immunization coverage in India has led to a large burden of vaccine-preventable diseases borne by children under 5 years of age. Despite efforts to strengthen infrastructure and service delivery in the past decade, immunization coverage rates have reached a plateau. To meet the formidable needs of India's growing population and address the shortcomings of health services for rural populations, the country is now turning toward a new national community health worker (CHW) plan. This article reviews the effectiveness of CHWs in expanding immunization coverage in developing countries and examines the potential contribution of CHWs toward strengthening immunization services in rural India. While the limited number and quality of available studies make it difficult to directly compare CHW interventions to other strategies for improving immunization coverage, it is clear that CHWs make diverse contributions toward strengthening immunization programs. Incorporation of evidence-based strategies for CHW selection, retention, and training is critical for success of India's immunization program. In addition, there is growing need to develop efficient mechanisms for monitoring children's vaccination status to generate actionable feedback and identify cost-effective strategies.     

Rural versus urban: Tennessee health administrators' strategies on recruitment and retention for allied health professionals

Due to an increase in the need for allied health professionals, there is a growing interest to assess the allied health workforce and its employment needs. This is especially true in medically underserved rural areas where there is a critical shortage of allied health professionals. A survey was sent to allied health administrators across a variety of allied health disciplines working in Tennessee hospitals in order to gauge opinions on retention and recruitment strategies. Overall successful strategies for recruitment and retention of allied health professionals were reported as well as differences between urban and rural areas, differences of perceptions of strategy effectiveness among allied health disciplines, and key strategies for rural allied health recruitment. Little is known about organizational policies impacting recruitment and retention practices of allied health professionals in Tennessee hospitals. Understanding of this problem is vital to the prevention of a critical shortage of allied health professionals. Therefore, this study sought to compare rural and urban hospital in Tennessee with respect to recruitment and retention needs.     

灾难性卫生支出的城乡差异及分配敏感性研究

目的:分析实现全民医保后我国灾难性卫生支出的发展趋势、城乡差异及分配敏感性状况。方法:利用中国家庭动态跟踪调查2012年与2014年数据,采用世界卫生组织关于灾难性卫生支出及分配敏感性计算的方法。结果:2012—2014年,灾难性卫生支出总体发生率和发生强度均有明显下降。总体而言,灾难性卫生支出的收入分配状况相对均等。但是,发生率绝对值较高,且城乡有别,农村受到的灾难性卫生支出冲击更大;穷富有别,灾难性卫生支出更多发生在穷人身上。2012年城市发生率比农村更不均等,2014年正好相反。2012—2014年,所有家庭平均差距的集中指数由负变正。结论:全民医保对于降低灾难性卫生支出发生率与发生强度有一定作用;有限的保障内容、水平可能导致医保无法改善甚至加剧灾难性卫生支出的强度;收入水平与医疗保险差异导致农村、穷人遭受更大的灾难性卫生支出发生风险。     

Are hard-to-reach populations being reached with immunization services? Findings from the 2005 Papua New Guinea national immunization coverage survey

Objective

To measure immunization coverage among children aged 12–23 months in Papua New Guinea (PNG) and to assess if and why there are differences between hard-to-reach and more accessible communities.

Methods

WHO cluster sampling methodology was employed to measure immunization coverage in PNG's four regions. Survey data were re-analyzed according to a local assessment of geographical accessibility indicated by census unit type: urban, rural and hard-to-reach. Census units were designated as hard-to-reach if they were five or more kilometres from a health centre.

Findings

Nationwide coverage for most antigens falls below the national target of 80% although there are regional differences with Islands performing the best. Late doses are a major concern: just 4% were fully immunized with valid (“on time”) doses by 1 year of age. Coverage was lower in both rural and remote communities: at 6 months 48% of children from urban units had received three valid doses of DTP-3 but only 16% in rural areas and 13% in hard-to-reach communities. Reasons for failure to immunize varied: 21% of mothers said their child was not immunized because distance, travel conditions or cost of transportation prevented access to local health centres; 27% cited a lack of knowledge or misconceptions about immunization; while 29% believed it was because of an issue with the health system.

Conclusions

Throughout PNG there is an urgent need to increase immunization coverage and to ensure that children are immunized on time according to the schedule. Both coverage and timeliness of doses are worse for children living in hard-to-reach and rural areas. Achieving national immunization targets requires improvements in health service delivery, including outreach, especially for remote and rural communities, as well as greater community education and social mobilisation in support of immunization services.     

Biopsychosocial imperatives from the rural perspective

Rural health issues are examined within a biopsychosocial framework by addressing three questions: what is meant by ‘rural’? what are rural health needs? what factors must be considered in understanding and addressing these needs?Probably the single most important characteristic distinguishing rural from urban areas is low population density. This factor is particularly important in terms of its impact on (1) communication and transportation patterns, (2) one's ‘sense of community’ and (3) the availability of specialized services and complex organizations and institutions.For statistical purposes two different definitional dichotomies exist: rural-urban and metropolitan-nonmetropolitan. Although the rural and nonmetropolitan populations are not conterminous, approximately the same percentage of the nation's population is included in each of the two categories. A serious misconception is that of equating agriculture with rurality. While most farmers live and work in rural areas only a small fraction of rural Americans are engaged in agriculture.In terms of health needs, infant mortality tends to be higher in nonmetropolitan than in metropolitan areas; and limitation of activity due to chronic conditions is more likely to occur among the nonmetropolitan than the metropolitan population. Similarly, the percent of people who perceive their health as either ‘fair’ or ‘poor’ is higher for the nonmetropolitan population. On the other hand, the incidence of acute conditions and disability days per person per year are lower for the nonmetropolitan population than for the metropolitan population. Limited data on mental health suggest that the halcyon picture of country life may be grossly distorted.Understanding and addressing rural health needs involves a close look at the social, economic and medical systems operating in rural America. Income and employment levels, and their interrelationship to nutrition, housing and transportation generally find rural areas at a disadvantage. Although attitudes and values between rural and urban populations differ, it is all too easy to exaggerate these differences. The areas of sharpest differences have to do with issues of morality, religion and political philosophy. Problems in the availability and accessibility of medical services—especially specialized services—continue to plague rural areas.Recently, the most important dynamic in rural areas has been the rapid population growth associated with urban-to-rural migration. Another important characteristic of rural America is its diversity. Greater diversity likely exists among rural areas than among urban areas. For example, some rural areas have medical systems that are as sophisticated as those found in most urban areas.Failing to recognize and appreciate the diversity within the rural sector may be the greatest impediment to designing and implementing effective public policies for dealing with rural health needs. Considerable research, recent books, the creation of statewide offices of rural health and the work of national organizations have been helpful in alleviating the misunderstanding which surrounds rural America, its health care needs and the ways to best address those needs.     

Health and the urban poor

Traditionally, cities have benefited from a disproportionateshare of the resources available for health care and, as a result,most developments in primary health care have been in ruralareas. Recently, however, attention has been called to the inequitiesthat exist within cities and to the rapid growth of the urbanpoor. This paper reviews the topic of primary health care andthe urban poor in developing countries. The disease patternsof the urban poor reflect the problems of underdevelopment andindustrialization. The few studies that focus upon the healthproblems of the urban poor demonstrate a prevalence of infectiousdiseases and malnutrition which is comparable to and often greaterthan that observed in rural populations. At the same time, however,the urban poor suffer the typical spectrum of chronic and socialdiseases. The magnitude of the health problems of the urbanpoor rarely emerges in city health statistics. This is eitherbecause the ‘unofficial’ squatters and shanty townor slum inhabitants do not appear in the statistics or becausetheir conditions are obscured by the enormous difference thatexists between their status and that of the urban elite. Atthe community level there is now evidence of relevant, constructiveand hopeful approaches to helping the urban poor through primaryhealth care. Although there are few analytical or evaluativeexaminations of such initiatives, it is possible to identifyemerging trends such as the development of neighbourhood healthprogrammes, the use of community health workers and attemptsto link hospital services with community health action. It remainsto be seen whether the health departments in any cities canbring about the co-ordination and support needed for the improvementof environmental and socio-economic conditions which are fundamentalfor improving health. Also, international agencies need to focusmore attention upon the particular plight of the urban poor.     

Unravelling the extent of inequalities in health across urban and rural areas: Evidence from a national sample in England

Studies of inequalities in health between rural and urban settings have produced mixed and sometimes conflicting results, depending on the national setting of the study, the level of geographic detail used to define rural areas and the health indicators studied. By focusing on morbidity data from a national sample of individuals, this study aims to examine the extent of inequalities in health between urban and rural areas, as well as inequalities in health across rural areas of England. Multilevel analyses for poor self-rated health, overweight and obesity, and common mental disorders are reported for a sample of 30,776 individuals aged 18 years and older (obtained from the Health Survey for England years 2000–2003 combined) and distributed across 3645 small areas classed in four categories: two groups of urban areas (Greater London area or ‘other cities’) and two types of rural settings (semi-rural areas or villages). Results show that rural dwellers were significantly less likely than residents of urban areas to report their health as being fair or poor and to report common mental disorders, independent of their socio-demographic characteristics. However, as for urban settlements, there were significant variations in health across semi-rural areas and across villages, indicating the presence of health inequalities within rural settings in England. These inequalities were not fully explained by the individual composition of the areas or by the available measures of area socioeconomic conditions, indicating that in rural contexts more specific factors may have significance for health. Different policies and services for health promotion and care may need to be targeted to different types of rural areas.     

我国医疗卫生服务城乡分割和上下分割的现状分析及解决思路探究

针对我国医疗卫生服务存在城乡分割、上下分割,即农村卫生服务滞后于城市、优质资源过分向大医院集中、基层医疗卫生资源短缺、服务能力不强、不能满足群众基本卫生服务需求等问题,剖析其原因,探索解决思路：通过建立城乡卫生四级网,加大中央财政对农村医疗基础设施的投入,推进城乡医院对口支援工作,健全城乡基本医疗保障体系,以及做好区域卫生规划、建立医疗服务联合体等形式,推进医院与社区一体化、县乡和乡村一体化,引导医疗资源向农村和基层流动,带动基层医疗卫生服务能力和水平的提升,改善基层医疗卫生的便利性和可及性。     

三亚市城乡居民健康素养对比分析

目的了解并比较三亚市城乡居民的健康素养情况,为制定政策提供有针对性的理论依据。方法通过多阶段随机抽样在三亚市城乡随机抽取1 414名居民作为调查对象,其中城镇居民710名,农村居民704名,应用健康素养调查问卷进行调查,计算各道题目的正确率,进行统计学分析。结果共回收1 410份问卷,分析显示,城乡居民对健康相关知识的理解、健康相关行为和技能的形成和掌握方面差异均有显著性;城镇居民得分明显高于农村居民,且随着文化程度的增加,得分逐渐增加;城镇居民对居住环境的满意程度明显高于农村居民。结论加强健康相关知识和技能的教育和干预,尤其是针对农村居民的健康干预,是提高健康素养、促进三亚市城乡居民健康生活的重要措施。     

贫困农村妇女对基本生育卫生服务的需求、需要及满足

根据在青海省互助县,贵州省大方县、河南省嵩县、山西省榆社４个贫困县开展的《改善农村生育卫生服务》项目工作的基线调查资料,分析了贫困妇女对基本生育卫生服务的需要和需求,并探讨了满足妇女需要及需求的对策。指出,贫困妇女对基本生育卫生服务的需要和需求是巨大的,而且远远未被满足。妇女对基本生育卫生服务的需求包括：生育健康保健知识、优质,低价、方便的服务以及自主选择避孕方法。满足妇女需要、需求的措施包括：有     

Rural-Urban Differences in Health Insurance Coverage and Patterns Among Working-Age Adults in Kentucky

Context: Past studies show that rural populations are less likely than urban populations to have health insurance coverage, which may severely limit their access to needed health services. Purpose: To examine rural-urban differences in various aspects of health insurance coverage among working-age adults in Kentucky. Methods: Data are from a household survey conducted in Kentucky in 2005. The respondents include 2,036 individuals ages 18-64. Bivariate analyses were used to compare the rural-urban differences in health insurance coverage by individual characteristics. Logistic regression analyses were used to examine the independent impact of rural-urban residence on the various aspects of health insurance coverage, while controlling for the individuals’ health status and sociodemographic characteristics. Findings: The overall rate of working-age adults with health insurance did not differ significantly between the rural and urban areas of Kentucky. However, there were significant rural-urban differences in insurance for specific types of health care and in patterns of insurance coverage. Rural adults were less likely than urban adults to have coverage for vision care, dental care, mental health care, and drug abuse treatment. Rural adults were also less likely to obtain insurance through employment, and their current insurance coverage was, on average, of shorter duration than that of urban adults. Conclusions: In Kentucky, the overall health insurance rate of working-age adults is influenced more by employment status and income than by whether these individuals reside in rural or urban areas. However, coverage for specific types of care, and coverage patterns, differ significantly by place of residence.     

三亚市城乡居民健康素养对比分析

目的了解并比较三亚市城乡居民的健康素养情况,为制定政策提供有针对性的理论依据。方法通过多阶段随机抽样在三亚市城乡随机抽取1 414名居民作为调查对象,其中城镇居民710名,农村居民704名,应用健康素养调查问卷进行调查,计算各道题目的正确率,进行统计学分析。结果共回收1 410份问卷,分析显示,城乡居民对健康相关知识的理解、健康相关行为和技能的形成和掌握方面差异均有显著性;城镇居民得分明显高于农村居民,且随着文化程度的增加,得分逐渐增加;城镇居民对居住环境的满意程度明显高于农村居民。结论加强健康相关知识和技能的教育和干预,尤其是针对农村居民的健康干预,是提高健康素养、促进三亚市城乡居民健康生活的重要措施。     

杭州市城乡社区人群腹泻病发病及就诊情况调查

目的了解杭州市城乡社区人群腹泻病发病水平、就诊情况及医疗费用等。方法采取整群抽样的方法抽取上城区2个社区和萧山区3个乡镇居民作为调查对象,共4次入户调查了解其2周内腹泻病发生情况、就诊情况以及因腹泻病产生的各类医疗费用等。结果杭州市共调查了41496人,腹泻病年发病率为0.32次/人年,其中农村年发病率0.41次/人年,高于城市的0.23次/人年。7月和10月是腹泻病高发季节,5岁以下年龄组及55岁以上年龄组两周发病率较高。杭州市腹泻病的就诊率为31.01%,城乡差异无统计学意义,医疗治疗总费用人均为76.08元,报销费用占医疗就诊总费用的15.05%。结论杭州市腹泻病发病率较高,5岁以下儿童及老年人是高发人群,应进一步提高城乡居民患病后的就诊率。     

Strategies to improve immunization services in urban Africa

The urban poor constitute a rapidly increasing proportion of the population in developing countries. Focusing attention on underserved urban slums and squatter settlements will contribute greatly to immunization programme goals, because these areas account for 30-50% of urban populations, usually provide low access to health services, carry a large burden of disease mortality, and act as sources of infection for the city and surrounding rural areas. Improvement of urban immunization programmes requires intersectorial collaboration, use of all opportunities to vaccinate eligible children and mothers, identification of low-coverage neighbourhoods and execution of extra activities in these neighbourhoods, and community mobilization to identify and refer persons for vaccination. Improved disease surveillance helps to identify high-risk populations and document programme impact. New developments in vaccines, such as the high-dose Edmonston-Zagreb vaccine, will allow changes in the immunization schedule that facilitate the control of specific diseases. Finally, operational research can assist managers to conduct urban situation assessments, evaluate programme performance at the "micro" level, and design and monitor interventions.