Table 2.

Lessons learned from study on missed opportunities of vaccination in Dominican Republic (October 2012) and from other immunization surveys in Latin America (2010–2011)

Political support	-EPI should lead the study, even when international technical or financial support is available.
	-Cooperation among governmental agencies is required, particularly ministries of health, finance, and statistics.
	-EPI should start ethics approval process as soon as possible to prevent delays.
Country adaptation of instruments	-Sampling procedure must be carefully determined, preferably with assistance from a government statistician.
	-Surveys must be adapted to take into account differences in culture, local language, and EPI schedules.
	-Algorithms/syntaxes for determining missed opportunities must take into account replacement vaccines. A professional with expertise in computers and statistical programs should participate in the data analysis and address problems as they arise.
	-Survey questions must be understandable to all people regardless of education level.
	-Avoid technical language.
	-Professionals in different disciplines, including those outside of healthcare, should review questionnaires.
	-Pilot project or focal groups conducted prior to study implementation are key to adapting surveying instruments to local realities.
Implementation	-Role-play and the use of sample vaccination cards are useful tools in training interviewers to properly conduct interviews.
	-Explaining the study’s potential impact to interviewers promotes their interest in and commitment to the study.
	-Request feedback on surveying tools from interviewers/supervisors (many are parents and provide useful feedback).
	-EPI should notify health facilities that they have been selected for a survey 1–2 days before implementation.
	-New technologies (e.g. Palm Pilots) may reduce paperwork and data entry errors and enable local decision makers to access to data more quickly.
	-A polling company, if cost-effective, allows EPI professionals to focus on technical issues and provides an independent perspective and surveying expertise.
	-Properly-trained supervisors are key to ensuring that the questionnaire is properly administered and to minimizing data-entry errors.
	-Supervisors should seek to have health facility directors distribute the health worker survey at grand rounds or during shift changes.
Data analysis and design of Interventions	-EPI professionals at all levels--local, sub-national, national--should review results and be asked for suggestions to reduce MOVs.
	-To promote their involvement in the study and the design of local interventions, directors of evaluated health facilities should receive results.
	-Results should be published to increase understanding on the causes of under vaccination, establish a baseline for progress, and advocate for funding.
	-Reports should not be overly detailed. Too much information may obscure the study’s principal findings.
	-Report should advocate that study be repeated once interventions are implemented so that progress can be measured.