Face to Face Interventions for Informing or Educating Parents about Early Childhood Vaccination

"Vaccine program managers, policy makers and other decision makers need high-quality randomised trial evidence on the effects of face to face information and education interventions for parents."

This review of literature on randomised controlled trials (RCTs) and cluster RCTs was a part of a 2-year, multi-stage research project called Communicate to Vaccinate (COMMVAC) (see Related Summaries, below, for more information). The COMMVAC project focused on building the evidence on communication interventions to improve childhood vaccination rates. While the COMMVAC project had a particular emphasis on low- and middle-income countries (LMICs), this review is global in scope. The impetus for the review was an identification on the part of participants in deliberative forums held from June to July 2011 who identified face-to-face information or education interventions as a widely used strategy of relevance to, for example, meet the Millennium Development Goal (MDG) of reducing child mortality.

Opening sections of the document provide context about vaccination, described here as "a beneficial and cost-effective public health measure and has led to the global eradication of smallpox and large reductions in polio, measles, tetanus, rubella, diphtheria, and Haemophilus influenzae type b....Routine vaccination is not only a crucial issue in LMICs. High-income countries (HICs) also experience equity-related challenges to achieving universally high coverage rates. Equity features which can affect coverage include indigenous or ethnic status, poverty, large family size, and low educational attainment....Another cause of regional vaccination coverage variation in HICs is individuals who refuse some or all vaccination for their children...."

The focus of this review is on face-to-face information or education interventions (e.g., oral presentations, one-on-one or group classes or seminars, information sessions, or home outreach visits), which are designed to address barriers related to knowledge, beliefs, or attitudes (misinformation; parental fear about safety; and/or lack of awareness about vaccine schedule, doses, or vaccine-preventable diseases). "Information or education interventions are important even in countries or settings where obvious barriers to vaccination do not exist. The right to health, including access to health information, is a fundamental human right which has been codified in United Nations and regional human rights treaties recognised internationally..."

Data collection and analysis for the review are outlined in detail. In short, based on the criteria, the researchers identified a total of 11,605 records from electronic database searches and 1,277 records from other sources; eventually, they included 7 trials described in 8 papers (2 papers reported different outcomes of the same trial). One study was a cluster RCT; the remaining 6 were RCTs. Three studies involved between 100 and 250 participants, and 4 had more than 400 participants, including 2 studies with 1,500 participants. The majority of interventions were directed to mothers, though the intervention in one study was directed to expectant parents. Four studies were conducted in HICs: Australia, Canada, and the United States. Two studies were conducted in Pakistan (lower-middle income) and 1 in Nepal (low income). One study took place in a rural setting; the rest were in urban or peri-urban locations. The information and/or education interventions comprised a mix of single-session and multi-session strategies.

Per the researchers: "The quality of the evidence for each outcome was low to very low and the studies were at moderate risk of bias overall. All these trials compared face to face interventions directed to individual parents with control. The three studies assessing the effect of a single-session intervention on immunisation status could not be pooled due to high hetero-geneity. The overall result is uncertain because the individual study results ranged from no evidence of effect to a significant increase in immunisation. Two studies assessed the effect of a multi-session intervention on immunisation status. These studies were also not pooled due to heterogeneity and the result was very uncertain, ranging from a non-significant decrease in immunisation to no evidence of effect. The two studies assessing the effect of a face to face intervention on knowledge or understanding of vaccination were very uncertain and were not pooled as data from one study were skewed. However, neither study showed evidence of an effect on knowledge scores in the intervention group. Only one study measured the cost of a case management intervention. The estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care. The review also considered the following secondary outcomes: intention to vaccinate child, parent experience of intervention, and adverse effects. No adverse effects related to the intervention were measured by any of the included studies, and there were no data on the other outcomes of interest."

In conclusion, the researchers explain that their review revealed that face-to-face strategies "do not consistently improve either immunisation rates or parent knowledge and understanding of vaccination, but the evidence was low to very low quality for these outcomes....No studies measured parents' intention to vaccinate their child or parent experience of intervention, and none of the studies looked at possible harmful outcomes related to the intervention. The results of this review are limited by the small number of included studies, small number of outcomes measured and problems with the way the researchers decided who should receive the intervention and with the way outcomes were assessed."