Table 3.

Interventions and selected immunization outcomes among studies which evaluated interventions to increase routine immunization coverage in an urban setting.

Author, Year published	Reference No.	Population: City, Country (urban, Peri- urban, or slum)a	Study design	Date of intervention	Length of intervention	Intervention description	Number of study subjects in control/comparator groups	Outcome(s)
								Indicator	Preb/controlc	Postb/ interventionc	Change
Anjum (2004)	17	Karachi, Pakistan (slum)	RCTd and pre-post	1998–2002	4 yr	Undergraduate medical students visited families, identified health knowledge gaps, delivered pre- tested health education messages twice in six months to mothers with children less than 5 years of age and vaccinated children present in the household	Control, BCG: 149 Intervention, BCG: 201	BCG immunization status among children under 5k	81%c	93%c	+24%
							Control, OPV3: 126 Intervention, OPV3: 156	OPV3 immunization status among children under 5k	65%c	84%c	+38%
							Control, DPT3: 46 Intervention, DPT3: 51	DTP3 immunization status among children under 5k	56%c	77%c	+31%*
							Control, Measles: 99 Intervention, Measles: 125	Measles immunization status among children under 5k	58%c	74%c	+23%*
Brugha (1996)	15	Nkawkaw, Kwahu Praso, Akwasiho, Ghana (urban)	RCTd	1991–1992	6 mo	Children who failed to report to a clinic following referral were visited up to 3 times over the following 6 months to give repeated messages about returning to the clinic for immunization	Control: 200 Intervention: 219	Fully immunizede,n	67%c	86%c	+19%*
Cutts (1990)	16	Inhambane, Beira, Tete, and Quelimane, Mozambique (urban)	Pre/post	1986	12 mo	Twice a year, community representatives visited homes of target groups, checked the immunization status of children and referred eligible children to the nearest health center using referral cards for a ‘pulse’ immunization session. Health workers collected referral cards upon vaccination at the health center	210 children per district selected for EPI cluster surveys at baseline and follow-up	Fully immunized children 12–23 months of age, Beira districte,g	55%b	51%b	−4%
								Fully immunized children 12–23 months of age, Tete districte,g	23%b	55%b	+22%
								Fully immunized children 12–23 months of age, Quelimane districte,g	27%b	60%b	+33%
								Fully immunized children 12–23 months of age, Inhamabane districte,g	39%b	53%b	+14%
Emond (2002)	18	Natal, Brazil (urban)	Pre/post	1994–1997	30 mo	As part of the ‘ProNatal’ project, maternity facilities were improved, antenatal and family planning clinics were established, community health agents (CHAs) were introduced, and public health education was provided to medicine and nursing students at local universities	Baseline: 1195 Follow-up: 1210	BCG immunization statush	76%b	93%b	+17%*
								OPV3 immunization statush	48%b	54%b	+6%*
								DTP3 immunization statush	62%b	65%b	3%
								Measles immunization statush	52%b	72%b	+20%*
Hughart (1991)	13	Dhaka, Bangladesh (slum)	Cross- sectional	1987–1988	13 mo	Illiterate/semi-literate women volunteers provided immunization education, referred women and children to clinics for immunization, accompanied women and children to the clinic, and followed up with mothers that did not return to the clinic using a simple record-keeping booklet	789 referrals of children > 2 mo overdue for any immunization	Percent of fully immunized (BCG, DTPx2, OPVx3, measles) children <24 months of age, among those who received referralsj	No control	87%	N/A**
Igarashi (2010)	19	Lusaka, Zambia (peri- urban)	Pre/post	2002–2005	9 mo (primary), 33 mo (lagged, intervention started 2 years after primary area)	Growth Monitoring Plus (GMP+) sessions, at which medical personnel provided immunization and community volunteers provided other health services (growth monitoring, nutrition counseling, health education, and Vitamin A supplementation), were held monthly	Primary (baseline): 192 Primary (final): 174	Fully immunized at 12mo, primary areae,g	53%b	69%b	+16%*
							Lagged (baseline): 183 Lagged (final): 187	Fully immunized at 12mo, lagged areae,g	48%b	57%b	+9%
Loevinsohn (1992)	26	Khartoum, El Obeid, Sudan (urban)	RCTd (crossover)	NR	1 day for each intervention (A and B) at 12 health centers	Two interventions aimed to increase the likelihood of vaccination among eligible children that had not attended the clinic specifically for immunization: Intervention A. The immunization table and vaccinator was moved from a side room to the front of the consultation room (an accessible and visible location) Intervention B. Mothers were given a referral to the regular immunization room by the clinician	Intervention A: 79	Percentage of eligible children <12 months of age immunized on day of the interventioni	No control	Intervention A: 61%	N/A
							Intervention B: 93			Intervention B: 66%
Owais (2011)	23	Karachi, Pakistan (urban, peri- urban)	RCTd	2008–2009	4 mo	In the intervention arm, community health workers visited mothers at home and used pictorial cards to educate mothers about vaccination, conveying 3 messages: 1) vaccines save lives; 2) logistic information (time and location of immunization sessions); 3) importance of retaining immunization cards; the control group received a general health promotion message	Control: 178 Intervention: 179	DTP3 immunization status 4 months post-enrollment (4–5 months of age)g	52%	72%	+20%*
Pradhan (2012)	21	Patna, India (urban)	Pre/post	2008–2010	12 mo	The number of immunization sites was increased, logistical planning for routine immunization sessions was improved, community mobilization activities were undertaken, supportive supervision of health workers was improved, data flow was strengthened and immunization drives implemented	Target population (using census data: ~24,000 Note: Coverage calculated using administrative reports of doses administered and target population estimation using census data	BCG coverageh	29%b	64%b	+35%**
								DTP3 coverageh	21%b	49%b	+28%**
								Measles coverageh	23%b	51%b	+28%**
Ryman (2012)	25	Homa Bay, Kenya (urban)	Pre/post	2009–2010	12 mo	At routine immunization visits, education about hand hygiene/drinking water treatment and storage was provided by nurses and hand hygiene kits were distributed	2–20 months 769	Percentage of doses received for which child due, 2–20 months of ageg	68% (61– 74%)b	84% (80– 86%)b	+16%*
							2–13 months 440	Child up-to-date, 2– 13 months of agef,g	69% (59– 78%)b	82% (78– 85%)b	+13%*
							4–13 months 440	DTP1–3 dropout, 4– 13 months of ageg	21% (13– 32%)b	9% (6–13%)b	−12%*
Sasaki (2011)	22	George Proper, Zambia (Peri- urban)	Pre/post	2003–2006	3 yr	Growth Monitoring Plus (GMP+) sessions, at which medical personnel provided immunization and community volunteers provided other health services (growth monitoring, nutrition counseling, health education, and Vitamin A supplementation), were held monthly	Baseline: 247 Follow-up: 268	DTP3 immunization status of children under age 5g	76%b	87%b	+11%**
								Measles immunization status of children under age 5g	67%b	76%b	+9%**
Tandon (2012)	14	India (urban)	RCTd	1983–1988	>5 yr	The Integrated Child Development Servicesprogram used community volunteers to provide nutrition and health education and services to children and pregnant/lactating mothers. Volunteers listed infants to be vaccinated, motivated acceptance of vaccination, assisted health teams in performing vaccination, and managed adverse events	Control: 126 Intervention: 1715	BCG coveragek	7%c	81%c	+74%**
								DTP3 coveragek	1%c	75%c	+74%**
								OPV3 coveragek	2%c	75%c	+73%**
Uddin (2009)	27	Dhaka, Bangladesh (slum)	Pre/post	2006–2007	12 mo	EPI service schedules were extended, training for service providers in valid/invalid doses and side effect management was offered, screening tools were used in non-EPI centers to refer to EPI centers, an EPI ’support group’ of community members was created to advocate for immunization	Baseline: 529 Follow-up: 526	Fully immunized at 12mo, among children aged 12– 23 monthsl	43%b	99%b	+56%*
								Fully immunized at 12mo, among children aged 12– 23 months (working mothers only)l	14%b (n = 227)	99%b (n = 242)	85%*
								DTP1–3 dropout, among children aged 12– 23 monthsl	33%b	1%b	−32%*
Usman (2009)	24	Karachi, Pakistan (urban)	RCTd	2003	3 mo	Redesigned immunization cards with the next scheduled vaccination date in large print were given to caretakers, either alone or in combination with a 2–3 min education session given by a study personnel member emphasizing importance of immunization schedule completion	Redesigned card arm: 375		55%c	74%c	+19%*
							Education arm: 375	Received DTP3 during 90 days follow-up (education only vs. standard care)m
							Card + education arm: 375	Received DTP3 during 90 days follow-up (education and redesigned card vs. standard care)m	55%c	65%c	+10%*
							Standard care only arm: 375
Zimicki (1994)	20	Manila, Philippines (urban)	Pre/post	1990	5 mo	A media campaign focused on measles immunization, emphasizing a particular day of the week that measles immunization was provided	Baseline: 446 Follow-up: 461	Fully immunized, children aged 12–23 monthsl	54%b	65%b	+11% (3– 19%)*

NR = not reported.

Mo = month.

Yr = year.

^*Significant change (no * indicates a non-significant result). In Anjum et al., represents a significant change in the intervention but not the control area in the survey after compared to the survey before the intervention.

^**Did not report measures of statistical significance for this outcome.

^abased on the author’s designation of the study area.

^bPercentages refer to pre-intervention and post-intervention values.

^cPercentages refer to control group and intervention group values.

^dRCT: Randomized controlled trial.

^eFully immunized: immunized with BCG, DTP1–3, OPV1–3, and measles-containing vaccine (unless otherwise noted).

^fUp-to-date: child has received all recommended vaccinations for their age.

^gVaccination status determined by card only (no recall).

^hCoverage determined by administrative estimates.

ⁱVaccination status determined by health clinic vaccination records.

^jVaccination status determined by health worker’s collection of referral slip at vaccination visit.

^kMethod of vaccination status determination not reported.

^lVaccination status determined by card or recall.

^mVaccination status determined by records of study personnel stationed at health facility.

ⁿVaccination status determined by card or clinic vaccination records.