OBJECTIVE: Progress towards the Millennium Development Goals for maternal health has been slow, and accelerated progress in scaling up professional delivery care is needed. This paper describes poor-rich inequalities in the use of maternity care and seeks to understand these inequalities through comparisons with other types of health care. METHODS: Demographic and Health Survey (DHS) data from 45 developing countries were used to describe poor-rich inequalities by wealth quintiles in maternity care (professional delivery care and antenatal care), full childhood immunization coverage and medical treatment for diarrhoea and acute respiratory infections (ARI). FINDINGS: Poor-rich inequalities in maternity care in general, and professional delivery care in particular, are much greater than those in immunization coverage or treatment for childhood illnesses. Public-sector inequalities make up a major part of the poor-rich inequalities in professional delivery attendance. Even delivery care provided by nurses and midwives favours the rich in most countries. Although poor-rich inequalities within both rural and urban areas are large, most births without professional delivery care occur among the rural poor. CONCLUSION: Poor-rich inequalities in professional delivery care are much larger than those in the other forms of care. Reducing poor-rich inequalities in professional delivery care is essential to achieving the MDGs for maternal health. The greatest improvements in professional delivery care can be made by increasing coverage among the rural poor. Problems with availability, accessibility and affordability, as well as the nature of the services and demand factors, appear to contribute to the larger poor-rich inequalities in delivery care. A concerted effort of equity-oriented policy and research is needed to address the huge poor-rich inequalities in maternity care.

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Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries.

Every year nearly 11 million children die before reaching their fifth birthday and most of them during their first year of life. Most of these deaths (98% in 2002) are in developing countries; more than half are due to acute respiratory infections diarrhoea measles malaria and HIV/AIDS. In addition malnutrition underlies 54% of all child deaths. Projections based on the 1996 analysis The Global Burden of Disease indicate that these conditions will continue to be major contributors to child deaths in 2020 unless significant efforts are made to control them. In response to this challenge the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) developed the Integrated Management of Childhood Illness (IMCI) strategy which focuses on these five conditions and which includes three main components: Improvements in the case management skills of health workers through the provision of locally adapted guidelines on IMCI and through activities to promote their use. Improvements in the health system that are required for the effective management of childhood illness. Improvements in family and community practices. This paper addresses improvements in family and community practices. More specifically it presents the evidence for twelve key practices (see below) identified by UNICEF and WHO to be of key importance in providing good home-care for the child concerning the prevention or treatment of the IMCI conditions in order to ensure survival reduce morbidity and promote healthy growth and development. It does not include the four additional practices added following a meeting of UNICEF the WHO Regional Office for Africa and nongovernmental organizations(NGO) which took place in Durban South Africa in June 2000 as these practices will need additional work to reach a specificity whose impact can be measured. (excerpt)

Family and community practices that promote child survival growth and development. A review of the evidence.

Background
The Expanded Program on Immunization (EPI) is still in need of improvement. In Burkina Faso in 2003, for example, the Nouna health district had an immunization coverage rate of 31.5%, compared to the national rate of 52%. This study identifies specific factors associated with immunization status in Nouna health district in order to advance improved intervention strategies in this district and in those with similar environmental and social contexts.

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Assessment of factors associated with complete immunization coverage in children aged 12-23 months: a cross-sectional study in Nouna district, Burkina Faso.

Mathematical models can be used as health policy tools and predictive tools. Here we review how mathematical models have been used both to predict the consequences of specific epidemic control strategies and to design epidemic control strategies. We review how models have been used to evaluate the potential impact on HIV epidemics of (i) combination antiretroviral therapies (ART) and (ii) imperfect vaccines. In particular, we discuss how models have been used to predict the potential effect of ART on incidence rates, and to predict the evolution of an epidemic of drug-resistant HIV. We also discuss, in detail, how mathematical models have been used to evaluate the potential impact of prophylactic, live-attenuated and therapeutic HIV vaccines. We show how HIV vaccine models can be used to evaluate the epidemic-level impact of vaccine efficacy, waning in vaccine-induced immunity, vaccination coverage level, and changes (increases or decreases) in risky behavior. We also discuss how mathematical models can be used to determine the levels of cross-immunity that vaccines will need to attain if they are to be used to control HIV epidemics in countries where more than one subtype is being transmitted.

Forecasting the future of HIV epidemics: the impact of antiretroviral therapies & imperfect vaccines.

Background
A range of strategies are used to communicate with parents, caregivers and communities regarding child vaccination in order to inform decisions and improve vaccination uptake. These strategies include interventions in which information is aimed at larger groups in the community, for instance at public meetings, through radio or through leaflets. This is one of two reviews on communication interventions for childhood vaccination. The companion review focuses on face-to-face interventions for informing or educating parents.

Objectives
To assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.

Search methods
We searched CENTRAL, MEDLINE, EMBASE and five other databases up to July 2012. We searched for grey literature in the Grey Literature Report and OpenGrey. We also contacted authors of included studies and experts in the field. There were no language, date or settings restrictions.

Selection criteria
Individual or cluster-randomised and quasi-randomised controlled trials, interrupted time series (ITS) and repeated measures studies, and controlled before-and-after (CBA) studies. We included interventions aimed at communities and intended to inform and/or educate about vaccination in children six years and younger, conducted in any setting. We defined interventions aimed at communities as those directed at a geographic area, and/or interventions directed to groups of people who share at least one common social or cultural characteristic. Primary outcomes were: knowledge among participants of vaccines or vaccine-preventable diseases and of vaccine service delivery; child immunisation status; and unintended adverse effects. Secondary outcomes were: participants' attitudes towards vaccination; involvement in decision-making regarding vaccination; confidence in the decision made; and resource use or cost of intervention.

Data collection and analysis
Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed risk of bias in all included studies.

Main results
We included two cluster-randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.

The trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine-preventable diseases among intervention participants (adjusted mean difference 0.121, 95% confidence interval (CI) 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (risk ratio (RR) 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (diptheria, pertussis and tetanus) (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted mean difference 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision-making regarding childhood vaccination (adjusted mean difference 0.043, 95% CI -0.009 to 0.097).

The studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.

Authors' conclusions
This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.’

Interventions aimed at communities to inform and/or educate about early childhood vaccination.

OBJECTIVE: To assess the impact of the National Immunization Days (NIDs) on measles vaccine coverage in Burkina Faso in 1998. METHODS: During the week after the campaign, in which measles vaccine was offered to children aged 9-59 months in six cities regardless of vaccination history, a cluster survey was conducted in Ouagadougou and Bobo Dioulasso, the country’s two largest cities. Interviewers visited the parents of 1267 children aged up to 59 months and examined vaccination cards. We analysed the data using cluster sample methodology for the 1041 children who were aged 9-59 months. FINDINGS: A total of 604 (57%) children had received routine measles vaccination prior to the campaign, and 823 (79%) were vaccinated during the NIDs. Among those who had previously had a routine vaccination, 484 (81%) were revaccinated during the NIDs. Among those not previously vaccinated, 339 (78%) received one dose during the NIDs. After the campaign, 943 (91%) children had received at least one dose of measles vaccine. Better socioeconomic status was associated with a higher chance of having been vaccinated routinely, but it was not associated with NID coverage. CONCLUSION: The mass campaign enabled a substantial increase in measles vaccine coverage to be made because it reached a high proportion of children who were difficult to reach through routine methods.

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A. Valian

Papers

Mass measles vaccination in urban Burkina Faso, 1998