Monitoring and addressing determinants of vaccine utilization in low and middle income country settings: parental attitude scales and vaccine reminder interventions Restricted; Files Only

Wallace, Aaron (Spring 2018)

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To protect against vaccine-preventable diseases, which are leading causes of childhood mortality in several low and middle income countries (LMIC), infants are recommended to receive at least three doses of diphtheria-tetanus-pertussis containing vaccine (DTPcv). In several countries, a substantial proportion of children receive only the first DTPcv dose, leaving them vulnerable to illness.


Despite concerns that parental hesitancy may contribute to incomplete vaccination, little work has occurred in LMICs to develop tools to monitor hesitancy trends.  Additionally, lack of parental awareness of future visits is a common determinant of incomplete vaccination. However, little is known about the effects and costs of interventions designed to remind parents of future vaccination visits in LMICs.


In dissertation aim 1, we developed a scale to assess parents’ hesitancy about childhood vaccination among a sample of 373 respondents in Ghana. Our final valid and reliable scale was composed of three parental attitude domains: vaccination benefits, vaccine safety & efficacy, and past vaccination behavior.  Parents who scored higher on the scale were more likely to have a child with incomplete and delayed vaccinations.


In aim 2, we implemented a cluster-randomized trial in 90 health facilities of Indonesia to test the effectiveness of two interventions designed to remind parents of future vaccination visits.  In each intervention, children received and kept a home-based vaccination record; in one intervention group, an appointment reminder sticker was placed on the record.  A higher proportion of children in the reminder-sticker group received a timely vaccination; however, by the end of 7 months, vaccination rates were similar across all groups.


In aim 3, we examined the costs of the Indonesia reminder interventions and the cost-effectiveness of the sticker intervention group.  The costs of each intervention where both low at about $0.50 per targeted child; for the reminder-sticker group, the cost-effectiveness ratio was below the costs of similar strategies Indonesia uses to improve timely completion of  childhood vaccinations.


Taken together, these studies provide robust evidence for future development of tools and strategies designed to monitor and address why children remain incompletely vaccinated in low and middle income country settings.

Table of Contents




Chapter 1: Background and Significance. 1


Pre-vaccine burden of vaccine preventable diseases. 1


The Expanded Programme on Immunization. 2


Global immunization goals and strategies. 4


Global routine immunization performance and impact 5


Top countries with lowest routine vaccination performance. 8


Key immunization program monitoring indicators. 9


Monitoring vaccine utilization. 11


Vaccine utilization determinants. 12


Vaccine hesitancy: a determinant of utilization. 13


Examples of measuring vaccine hesitancy trends. 14


Improving vaccine utilization: Parental reminder strategies. 17


Feasibility of home-based records as a parental reminder for vaccination. 20


Key knowledge gaps. 22


Dissertation aims. 24


Chapter 2: Aim 1 Manuscript 26


Introduction. 29


Methods. 31


Results. 36


Discussion. 40


Conclusion. 45


Supplemental Tables, Figures and Descriptions. 54


Chapter 3: Aim 2 Manuscript 58


Introduction. 61


Methods. 63


Results. 68


Discussion. 72


Conclusions. 76


Supplemental Information. 84


Chapter 4: Aim 3 Manuscript 85


Abstract 86


Introduction. 88


Methods. 90


Results. 94


Discussion. 96


Conclusions. 99


Tables and Figures. 100


Chapter 5: Conclusions and Future Directions. 116


Review of study findings. 117


Future directions: scales to assess caregiver attitudes towards vaccination. 121


Future directions: Vaccination reminders for caregivers. 122


References. 124


Appendix 1:  Aim 1 Questionnaire. 130




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