Research Article: Effect and cost-effectiveness of educating mothers about childhood DPT vaccination on immunisation uptake, knowledge, and perceptions in Uttar Pradesh, India: A randomised controlled trial

Date Published: March 6, 2018

Publisher: Public Library of Science

Author(s): Timothy Powell-Jackson, Camilla Fabbri, Varun Dutt, Sarah Tougher, Kultar Singh, James K. Tumwine

Abstract: BackgroundTo assess the effect of health information on immunisation uptake in rural India, we conducted an individually randomised controlled trial of health information messages targeting the mothers of unvaccinated or incompletely vaccinated children through home visits in rural Uttar Pradesh, India.Methods and findingsThe study tested a brief intervention that provided mothers face-to-face with information on the benefits of the tetanus vaccine. Participants were 722 mothers of children aged 0–36 months who had not received 3 doses of diphtheria–pertussis–tetanus (DPT) vaccine (DPT3). Mothers were randomly assigned in a ratio of 1:1:1 to 1 of 3 study arms: mothers in the first treatment group received information framed as a gain (e.g., the child is less likely to get tetanus and more likely to be healthy if vaccinated), mothers in the second treatment group received information framed in terms of a loss (e.g., the child is more likely to get tetanus and suffer ill health if not vaccinated), and the third arm acted as a control group, with no information given to the mother. Surveys were conducted at baseline (September 2015) and after the intervention (April 2016). The primary outcome was the proportion of children who had received DPT3 measured after 7 months of follow-up. The analysis was by intention to treat. A total of 16 (2.2%) participants were lost to follow-up. The coverage of DPT3 was 28% in the control group and 43% in the pooled information groups, giving a risk difference of 15 percentage points (95% CI: 7% to 22%, p < 0.001) and a relative risk of 1.52 (95% CI: 1.2 to 1.9, p < 0.001). The information intervention increased the rate of measles vaccination by 22 percentage points (risk difference: 22%, 95% CI: 14% to 30%, p < 0.001; relative risk: 1.53, 95% CI: 1.29 to 1.80) and the rate of full immunisation by 14 percentage points (risk difference: 14%, 95% CI: 8% to 21%, p < 0.001; relative risk: 1.72, 95% CI: 1.29 to 2.29). It had a large positive effect on knowledge of the causes, symptoms, and prevention of tetanus but no effect on perceptions of vaccine efficacy. There was no difference in the proportion of children with DPT3 between the group that received information framed as a loss and the group that received information framed as a gain (risk difference: 4%, 95% CI: −5% to 13%; p = 0.352; relative risk: 1.11, 95% CI: 0.90 to 1.36). The cost per disability-adjusted life year averted of providing information was US$186, making the intervention highly cost-effective with respect to the WHO-recommended threshold of once the gross domestic product per capita (US$793 in the case of Uttar Pradesh). Key study limitations include the modest sample size for this trial, limiting power to detect small differences in the framing of information, and the potential for contamination among households.ConclusionsProviding mothers of unvaccinated/incompletely vaccinated children with information on tetanus and the benefits of DPT vaccination substantially increased immunisation coverage and was highly cost-effective. The framing of the health information message did not appear to matter.Trial registrationThe trial is registered with ISRCTN, number ISRCTN84560580.

Partial Text: An estimated 5.9 million children die each year globally, of which 1.2 million are in India [1]. The majority of these deaths are preventable with existing low-cost health technologies, such as improved water and sanitation, zinc supplementation, oral rehydration solutions, and vaccines [2]. Indeed, such interventions have contributed to remarkable improvements in child mortality in many developing countries [1]. Despite well-documented evidence on the health and developmental benefits of immunisation [3], a huge number of children fail to get vaccinated. In Uttar Pradesh, a state of more than 200 million people and the setting for this study, only 51% of children aged 12 to 23 months are fully vaccinated [4].

Between 12 and 30 July 2015, 2,359 mothers were assessed for eligibility (Fig 1). Of these, 1,637 (69%) mothers were excluded, most commonly because the child had already received DPT3. Overall, 722 participants were enrolled and randomly assigned to 1 of the 3 treatment groups: information positively framed (n = 237), information negatively framed (n = 246), or no information (n = 239). A total of 16 (2.2%) participants were lost to follow-up, resulting in a final analytical sample of 706. There were no further missing data. Attrition was similar across treatment groups.

This paper presented evidence on the role of information in raising demand for immunisation in India. Our analysis yielded 3 key findings. First, providing mothers of unvaccinated or incompletely vaccinated children with information on tetanus and the benefits of vaccination substantially increased immunisation coverage of DPT3, full immunisation, and measles. The large effect on measles vaccination was not anticipated, given that the information intervention focused solely on tetanus. We speculate that the increase in measles vaccination was generated by increased engagement with the public health system and, in turn, health workers ensuring children were up to date on all their vaccines, not just DPT3. Second, the framing of the information did not appear to generate large differences in outcomes. Although the effects of negative framing were consistently larger than when information was framed as a gain, differences between the 2 groups were small and rarely significant. Third, information improved mothers’ knowledge of causes of, symptoms of, and methods of prevention against tetanus. There was no effect on perceptions of vaccine efficacy, but there was suggestive evidence of an increase in perceptions of efficacy for mothers who initially had inaccurate perceptions.

Our results demonstrate that targeted and clear information delivered to mothers of unvaccinated/incompletely vaccinated children can be effective in improving immunisation coverage. These findings contribute to a growing body of evidence on what are the most effective strategies to improve vaccination rates in developing countries. Although the barriers to immunisation uptake are multiple, ranging from social norms to the reliability of supply systems, in contexts where knowledge and awareness are a key binding constraint, interventions that provide information to parents and carers of unvaccinated children have the potential to be a simple and cost-effective way of increasing demand for immunisation.



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