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Far too many of the world’s children are not being vaccinated against often deadly but preventable childhood diseases. But now a Canadian initiative is helping researchers from Canada and around the world work together to identify and overcome barriers to childhood immunization in developing countries.  

Vaccinations against diseases that once killed young children are often heralded as the single-most effective advance in modern medicine. In an ideal world, every child would be routinely immunized, on schedule. Illnesses like diphtheria, pertussis (or whooping cough), tetanus, and measles would be on their way to being vanquished.

But in the real world, despite advances in immunization coverage and massive vaccination campaigns, those preventive needle jabs are still not reaching some of the poorest corners of the globe. That’s why the Global Health Research Initiative (GHRI), a partnership among four federal Canadian agencies — including IDRC — is supporting  the collaborative efforts of researchers in Canada and low- and middle-income countries to identify where, and why, immunization programs are failing. (See sidebar.)

Partnering for health

The Canadian International Immunization Initiative Phase II (CIII2) is funding six operational research projects in 12 developing countries to identify barriers to immunization, and to apply the knowledge learned to strategies on how best to overcome them.

In Burkina Faso, for example, only 52% of children under the age of 11 months get the routine childhood immunizations they need to fight disease and stave off preventable deaths. According to the World Health Organization (WHO), in 2006, measles was the most common preventable disease in Burkina Faso (more info).   Although the WHO’s Expanded Programme on Immunization (EPI) set a goal in 1990 of immunizing 90% of the world’s one-year-olds by 2000, the coverage rate in most developing countries has not come close to that target, despite the best efforts of years of immunization campaigns.

Gilles Bibeau from the Université de Montréal and Dr Bocar Kouyaté from the Centre de recherche en santé de Nouna in Burkina Faso are co-leaders of one of six CIII2 project teams looking at barriers to immunization. They designed a simple but effective program to dismantle those barriers: enlisting village godmothers and other community leaders.

Godmothers get families to clinics

Community leaders in 21 villages chose 85 women health leaders. The project team trained 75 godmothers, and another 10 village informants, to record births and apprise nurses of the number of children needing vaccinations. The godmothers follow up with families, inform them when immunization clinics are scheduled, and help get families to the clinics.    

“Basically, the idea of the intervention is that we don’t want to add extra fees or activities (to the existing immunization program),” says Dr Robert Kargougou, who works with Kouyaté at the Centre de recherche en santé de Nouna, in the province of Kossi.

Kargougou and about 20 other researchers presented their findings at a knowledge-to-practice workshop on global immunization, organized by GHRI last fall in Ottawa. Representatives from organizations that base policies and programs on these research findings also attended. They included the World Health Organization, UNICEF, the Pan American Health Organization, and other stakeholders such as the Canadian Public Health Association.

Two of the critical factors convincing decision-makers to support projects are their relative simplicity and cost-effectiveness, some researchers told the conference. For example, in the Burkina Faso project, the godmothers are reimbursed only for their travel expenses, yet maintain a sense of ownership throughout the process. The project strengthens existing capacity, since the godmothers are already aware of what’s going on in the village.

“They work with traditional healers, they know when the nurse comes, and where the new babies are,” Kargougou says. 

Mothers balance benefits of vaccination

One of the main obstacles to immunization identified by the Burkina Faso team was a lack of information about the timing of clinics. Even when mothers are aware of clinics, they must juggle their children’s need for vaccinations against their daily responsibilities. Sometimes, they may believe that if their child has one or two of the four boosters required for polio, missing a single injection will not harm them.

“Mothers want to see their children being protected against these preventable diseases,” says Bibeau. “They know that measles is dangerous and polio is dangerous.  But they have to balance the benefits for the whole family of going to the field, or the risk for their children of jumping over one shot.”

Thanks to the godmother program, when women are absent on vaccination clinic days, the godmothers find them and bring them to the village, making sure babies get immunized.

While the team in Burkina Faso is completing an evaluation of the program, preliminary reports indicate that attendance at the vaccination clinics is up.

“From what I’ve heard from the nurses, there is a lot of improvement,” Kargougou says.

If the results prove as successful as the researchers expect, their program could be duplicated throughout West Africa and in other countries where immunization coverage is low.

Complex cost-benefit calculations

Another research team working in areas of Pakistan where only half of children are vaccinated against measles discovered that the barriers to vaccination are complex. Often, those designing and delivering immunization programs assume people don’t take advantage of them because they don’t understand their benefits. That’s not true, say Neil Andersson of CIET Canada (Community Information and Epidemiological Technology Canada) and Noor Mohammed, of CIET in Pakistan.

“Our main finding was that people weigh out what they know about the benefits with how they live with the costs,” says Andersson.

Families weigh the frequency and cost of an illness in one or two years’ time against today’s costs of transportation to the clinic and of lost work time, Andersson says.

Included in the calculations are discount rates that vary with the ages and gender of their children.

The CIET team incorporated those calculations into an intervention program in Pakistan. In 34 communities they tested whether discussing the cost and benefit of vaccinating children against measles would improve coverage rates. Researchers talked to community groups in 18 sites about local evidence in favour of immunization, and about barriers. Research teams then helped communities develop action plans to disseminate the evidence for immunization. In the control group, 16 communities received no interventions.

After the first year, in the first communities, the number of measles vaccinations had risen by 20%, and DPT (diphtheria, pertussis, and tetanus) vaccinations by 28%, says Andersson.

The CIET team provided the district government with information from its survey, which has been well-received. The findings helped convince UNICEF to support the district department in carrying out more immunization outreach activities, to improve coverage in remote areas that don't have easy access to health services.

Transferring knowledge is crucial

Transferring the knowledge that these research projects are generating is crucial to improving overall vaccination rates, says Osman David Mansoor, senior advisor for EPI at UNICEF.

“It was good to see the projects address issues such as presenting information about immunization to parents in terms of costs and benefits, which lead to large increases in uptake; the need for better use of data by program managers; and the key role of leadership in achieving high coverage,” he says.

“The challenge with all of these projects will be to translate research findings into policy and implementing the operational research findings at national scale.”

The WHO needs the research data as soon as it has been validated, says Philippe Duclos, the organization’s senior health advisor for immunization, vaccines, and biologicals.

“The research projects are generating interesting results that may be of use, once confirmed, to adjust some of the WHO’s approaches to improving vaccine coverage, such as the Reaching Every District (RED) strategy,” says Duclos.

He urged the researchers to disseminate their findings as quickly as possible, overcoming any obstacles regarding intellectual property by publishing, if possible, in open access forums. “A speedy exchange of information is needed,” says Duclos.

Canadian researchers also welcomed the information, pointing out that immunization rates in Canada have been falling, and that they can also learn how to apply the knowledge of what prevents parents from vaccinating their children. 

Laura Eggertson is an Ottawa-based writer

About the Global Health Research Initiative

In 2001, four federal agencies formed a unique partnership to coordinate and increase the profile of Canada’s support for health research and its application in low- and middle-income countries (LMICs). The resulting Global Health Research Initiative (GHRI) supports innovative research and capacity-building programs and strategic South–North collaborations that improve the health and well-being of Canadians and the residents of developing countries. By working together, the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, and the International Development Research Centre strive to influence global health policy and research agendas, and to ensure knowledge is disseminated and applied as quickly as possible.

GHRI operates under the assumption that relatively modest investments in research on the health problems of LMICs and on global health priorities could go a long way toward improving health outcomes and lowering program costs.

Phase 2 of the Canadian International Immunization Initiative (CIII2) was launched as the first large-scale program funded by GHRI. Its goal is to strengthen and expand immunization services, build the capacity of local researchers in the South and Canada, and help identify why immunization programs are not succeeding. By identifying the barriers and applying that knowledge, the researchers hope to overcome them and increase immunization coverage.

The initiative supported six research teams that undertook projects in Benin, Burkina Faso, and Mali; Bolivia, Chile, Cuba, Nicaragua, Paraguay, and Peru; Burkina Faso; Georgia; India; and Pakistan. The researchers met in Ottawa in September 2007 for a knowledge-to-practice workshop that helped to disseminate their findings and inform future research.

2009

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