Interventions Aimed at Communities to Inform and/or Educate about Early Childhood Vaccination

Large numbers of qualitative and quantitative studies have explored the reasons for vaccine hesitancy and the non-vaccination of children. One barrier in many settings is parents being poorly informed and, consequently, being in doubt about the trade-offs between the benefits and harms of vaccination and having fears about side effects. The purpose of this Cochrane Review was to assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children 6 years and younger.

These strategies include interventions in which information is delivered to larger groups - for instance, through printed materials such as brochures, electronic media such as web-based programmes, and large-scale media such as television and radio; a companion review focuses on face-to-face interventions for informing or educating parents (see Related Summaries, below). Both reviews are part of a multi-stage research project called Communicate to Vaccinate (COMMVAC), which focuses on building research knowledge and capacity to use evidence-based strategies for improving communication about childhood vaccinations with parents and communities in low- and middle-income countries (LMICs).

The goal of the interventions covered in the review is to achieve outcomes such as: knowledge of vaccines, vaccine-preventable diseases (VPDs) or service delivery; increased involvement in decision-making; better-informed decisions and more confidence in the decision made regarding vaccination; and improved vaccination coverage. Interventions to inform or educate may be tailored to address low literacy levels and can also serve to address misinformation.

After searching CENTRAL, MEDLINE, EMBASE, and 5 other databases up to July 2012, as well as grey literature in the Grey Literature Report and OpenGrey, the researchers included in the review 2 cluster-randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India (2007), families, teachers, children, and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan (2009), people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans, to share the information they had been given, and to continue the discussions in their communities.

Key results:

• The trials show low-certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or VPDs among intervention participants (adjusted mean difference 0.121, 95% confidence interval (CI) 0.055 to 0.189).
• The study from India showed that the intervention probably increased the number of children who received vaccinations (risk ratio (RR) 1.67, 95% CI 1.21 to 2.31; moderate-certainty evidence).
• The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (diptheria, pertussis, and tetanus) (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate-certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low-certainty evidence).
• There is low-certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted mean difference 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision-making regarding childhood vaccination (adjusted mean difference 0.043, 95% CI -0.009 to 0.097).

In short, this review provides limited evidence to inform decisions regarding the implementation of interventions aimed at communities to inform and educate about early childhood vaccination. Some of these interventions, such as community meetings or some forms of mass media, may be resource intensive when implemented at scale. It may be beneficial to target interventions to areas or groups that have low childhood vaccination rates and therefore have the potential to benefit most. Other interventions, such as the use of electronic media directed to communities, may be less costly and possibly more feasible at scale. Where interventions directed by (as in the case of the Pakistan study) communities or aimed at communities are implemented, this should be in the context of rigorous evaluation so as to build the evidence base in this area.

The 2 studies identified were conducted in quite similar settings. One factor that needs to be considered in assessing whether the effects of interventions aimed at communities to inform and educate about childhood vaccination are likely to be transferable to other settings is whether there are important differences in on-the-ground realities and constraints that might substantially alter the feasibility and acceptability of the intervention.

Given the extensive use across many settings of interventions aimed at communities to inform and educate about early childhood vaccination, it is surprising to the Cochrane researchers that so few rigorous evaluations have been conducted. They indicate that trials or other rigorous evaluations are needed of: interventions aimed at communities and delivered by different groups of people; interventions aimed at communities and delivered via different mechanisms; and community-aimed interventions delivered in different geographical settings. They also call for further systematic reviews, including of studies of effects, process evaluations, and economic evaluations, on: people's views regarding the information they receive on childhood vaccination and on the types of information they would like to receive; the cost-effectiveness of interventions aimed at communities to inform and educate about early childhood vaccination; and the effects of other types of communication interventions for childhood vaccination.