Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization card and maternal education
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Summary: Objective A substantial dropout from the first dose of diphtheria‐tetanus‐pertussis (DTP1) to the 3rd dose of DTP (DTP3) immunization has been recorded in Pakistan. We conducted a randomized controlled trial to assess the effects of providing a substantially redesigned immunization card, centre‐based education, or both interventions together on DTP3 completion at six rural expanded programme on immunization (EPI) centres in Pakistan. Methods Mother‐child pairs were enrolled at DTP1 and randomized to four study groups: redesigned card, centre‐based education, combined intervention and standard care. Each child was followed up for 90 days to record the dates of DTP2 and DTP3 visits. The study outcome was DTP3 completion by the end of follow‐up period in each study group. Results We enrolled 378 mother–child pairs in redesigned card group, 376 in centre‐based education group, 374 in combined intervention group and 378 in standard care group. By the end of follow‐up, 39% of children in standard care group completed DTP3. Compared to this, a significantly higher proportion of children completed DTP3 in redesigned card group (66%) (crude risk ratio [RR] = 1.7; 95% CI = 1.5, 2.0), centre‐based education group (61%) (RR = 1.5; 95% CI = 1.3, 1.8) and combined intervention group (67%) (RR = 1.7; 95% CI = 1.4, 2.0). Conclusions Improved immunization card alone, education to mothers alone, or both together were all effective in increasing follow‐up immunization visits. The study underscores the potential of study interventions’ public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system.
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The highest median effect size was among educational interventions (median = 6.25).
“However, the highest median effect size was among educational interventions (median = 6.25)19,20.”
From Last-mile delivery increases vaccine uptake in Sierra Leone (2024) · cites this paper as [19]
The Results report risk ratios for individual trial groups, not median effect sizes across intervention categories. The Discussion says the redesigned card was more effective than education alone in this trial, but does not assess which category had the highest median effect size. Searches for “6.25” and “median educational interventions effect size” found no matching result in our copy. (LLM, conf=0.76)
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- Authors
- Usman, H. R., Rahbar, M. H., Kristensen, S., Vermund, S. H., Kirby, R. S., Habib, F., & Chamot, E.
- Affiliations
- University of Alabama at Birmingham (US)
- The University of Texas Health Science Center at Houston (US)
- Vanderbilt University (US)
- University of South Florida (US)
- Aga Khan University (PK)
- Corresponding author
- Usman, Hussain R.
- Venue
- Tropical Medicine & International Health
- Publisher
- Wiley
- Published
- 2010-12-15
- Volume
- 16
- Issue
- 3
- Pages
- 334-342
- ISSN
- 1360-2276 (ISSN-L)
- 1365-3156
- PMC
- PMC3763701
- OpenAlex
- W1586918305
- Cited by
- 89
- References
- 1
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 4 · 2023: 5 · 2022: 7 · 2021: 6 · 2020: 6 · 2019: 14 · 2018: 4 · 2017: 7 · 2016: 5 · 2015: 9 · 2014: 6 · 2013: 3 · 2012: 3
- FWCI
- 2.94
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Tropical Medicine & International Health (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- eCommons - AKU (Aga Khan University) (submittedVersion)
- Funders
- University of Alabama at Birmingham
- National Institutes of Health
- Fogarty International Center (D43TW005497)
- Topics
- Social Sciences › Health › Vaccine Coverage and Hesitancy
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Keywords
- childhood immunization, vaccine adherence, DTP vaccine, maternal education, Expanded Programme on Immunization, rural Pakistan, immunization dropout, mother-child pairs
- MeSH terms
- Assessment of Medication Adherence, Adolescent, Adult, Female, Health Education, Humans, Immunization Schedule, Infant, Infant, Newborn, Medical Records, Mothers, Pakistan, Patient Dropouts, Socioeconomic Factors, Diphtheria-Tetanus-Pertussis Vaccine, Drug Monitoring, Rural Health Services, Mass Vaccination, Medication Adherence, Young Adult
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