Improving Equity in Urban Immunization in Low- and Middle-Income Countries: A Qualitative Document Review

Abstract

Introduction: As the world continues to urbanize, particularly in low- and middle-income countries, understanding the barriers and effective interventions to improve urban immunization equity is critical to achieving both Immunization Agenda 2030 targets and the Sustainable Development Goals. Approximately 25 million children missed one or more doses of the diphtheria, tetanus and pertussis (DTP3) vaccine in 2021 and it is estimated that close to 30% of the world’s children missing the first dose of DTP, known as zero-dose, live in urban and peri-urban settings. Methods: The aim of this research is to improve understanding of urban immunization equity through a qualitative review of mixed method studies, urban immunization strategies and funding proposals across more than 70 urban areas developed between 2016 and 2020, supported by Gavi, the Vaccine Alliance. These research studies and strategies created a body of evidence regarding the barriers to vaccination in urban settings and potential interventions relevant to low- and middle-income countries (LMICs) with a focus on the vaccination of urban poor, populations of concern and residents of informal settlements. Through the document review we identified common challenges to achieving equitable coverage in urban areas and mapped proposed interventions. Results: We identified 70 documents as part of the review and categorized results across (1) social determinants of health, (2) immunization service-delivery barriers and (3) quality of services. Barriers and solutions identified in the documents were categorized in these thematic areas, drawing information from results in more than 21 countries. Conclusion: Populations of concern such as migrants, refugees, residents of informal settlements and the urban poor face barriers to accessing care which include poor availability and quality of service. Example solutions proposed to these challenges include tailored delivery strategies, improved use of digital data collection and child-friendly services. More research is required on the efficacy of the proposed interventions identified and on gender-specific dynamics in urban poor areas affecting equitable immunization coverage.

Reporting of social determinants of health in randomized controlled trials conducted in the pediatric intensive care unit

“…Finally, certain variables such as immunization status were rarely reported. While it could be argued that immunization status in some patients results from family preferences, there are also several studies suggesting an association between immunization rates and education levels, family income and access to care (51)(52)(53). In addition to be a potential surrogate for other social determinants of health, immunization status could be a confounder for illness severity in certain diseases and as such be important to report on in RCTs.…”

The influence of demographic and socio-economic factors on non-vaccination, under-vaccination and missed opportunities for vaccination amongst children 0–23 months in Kenya for the period 2003–2014

“…Given the limited access to healthcare infrastructure associated with home deliveries, it is likely to potentially result in MOV. The preference for home deliveries might be associated with lower health literacy or socio-economic challenges among mothers, impacting their awareness and ability to prioritize timely immunizations [44][45][46]. In contrast, children born in private health facilities are likely to receive immediate postnatal care, including vaccinations, in a controlled and supervised environment.…”