A Low-Cost, Integrated Immunization, Health, and Nutrition Intervention in Conflict Settings in Pakistan - The Impact on Zero-Dose Children and Polio Coverage

"[I]t is not only critical to engage, educate, and mobilize communities, particularly community elders and religious leaders, but also to provide these populations with much-needed health and nutrition services."

Pakistan is one of two countries globally still endemic for poliovirus. Researchers have linked community "polio fatigue" with weariness and cynicism regarding repeated polio immunisation activities when the same community's access to basic health and nutrition services remains limited. Thus, while increasing immunisation coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognising these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunisation, and nutrition services, was implemented in conflict-affected union councils (UCs) with high poliovirus transmission. The objective of this paper is to examine the coverage and utilisation of the intervention and its impact on immunisation coverage, care-seeking practices, and nutrition behaviours, while exploring the impact on zero-dose children. The vaccination-related outcomes and behaviours are reported in this paper; outcomes related to MNCH and nutrition will be presented and discussed in a separate publication.

Naunehal was implemented in three UCs of Pakistan: Kharotabad 1 (Quetta District, Balochistan Province) and Bhana Mari (Peshawar District, (KP) Province), which were classified as super-high-risk UCs (SHRUCs) by the Pakistan Polio Eradication Programme, and UC Bakhmal Ahmedzai in district Lakki Marwat, Khyber Pakhtunkhwa (KP), which is an area that has experienced polio outbreaks in recent years. These three UCs have also struggled with sub-optimal immunisation coverage, maternal and children-under-five-years-old health, and nutrition indicators.

The three main strategies in the intervention UCs included:

1. Community engagement and mobilisation: Awareness raising took place via health information sessions that focused on: routine childhood immunisation; optimal infant and young child feeding (IYCF) practices; water, sanitation, and hygiene (WASH); optimal diarrhoea management; and appropriate care seeking for both pregnant women and young children. A key component of the community mobilisation was ongoing engagement with local leaders and religious scholars to gain their support and buy-ins for the project activities and health messages.
2. Mobile health services: One team per UC, comprised of a female health worker, a vaccinator, and a facilitator, visited pre-determined areas of the UC six days a week. The services were designed in a way that the community was notified in advance of the visit date, and the service was scheduled to return to the same site again to coincide with the next vaccine doses, thus enhancing the convenience for the community and the uptake. The team provided basic health services, routine government-recommended immunisation and health services, and IYCF counseling geared toward children under five years old and women of reproductive age (WRA).
3. Engagement of private healthcare providers (HCPs): The project identified private HCPs in the intervention UCs to provide age-appropriate routine vaccinations to all under-five-year-old children visiting their clinics.

The project adopted a quasi-experimental pre–post design to assess the impacts of the interventions implemented between April 2021 and April 2022. The baseline survey was conducted in February-March 2021, while the endline survey was conducted in May 2022. For each of the intervention UCs, a separate, matched-control UC was identified. At baseline, 1,286 and 1,277 households were visited in the intervention and control UCs, respectively, and the data for 4,387 under-five-years-old children were collected. During the 12-month intervention period, the government's supplementary immunisation activities (SIAs) continued as scheduled in both the intervention and control UCs.

In the three intervention districts, the most common reasons provided by caregivers at baseline for not having their children vaccinated were a fear of side effects (19%) and a lack of faith in the immunisation (17.4%).

At endline, the proportion of fully immunised children increased significantly from 27.5% to 51.0% in intervention UCs, with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunisation (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group only. (The impact of the SIAs during the study intervention period explains the reduction in zero-dose children in both control and intervention UCs.)

An equity analysis showed that the intervention was successful in closing the equity gap for immunisation coverage, especially for Bacillus Calmette-Guérin (BCG), OPV 3, and Measles 1, "demonstrating that an effective outreach program accompanied by community mobilization was instrumental in reducing equity-related barriers."

There were also significantly positive impacts on vaccination card ownership and vaccination card retention.

Reflecting on the findings, the researchers note in particular that a key strength of the Naunehal model was a strong community engagement component, which not only included health information sessions with male and female community members and individual counseling sessions but also a key focus on engaging with religious and community leaders as an initial step. The programme's mobile health services and private practitioner engagements were not initiated until there was complete buy-in from community elders, which in turn inspired trust and motivation from the community members, making them more open to awareness-raising and knowledge-sharing sessions.

The researchers point to "the importance of using strategies that strive to 'reach the unreached' populations in conflict-affected, underserved locations. This outreach model provides a set of interventions with immunizations integrated with basic maternal and child health services and nutritional counseling. Importantly, the health services being offered enhance the probability of the community interacting with the services and increase the likelihood of community members using immunization services....The idea of a stand-alone 'polio program' is presently viewed with suspicion and disdain by many communities; thus, the integration of these activities with other health services can work to build community trust....Nevertheless, the skepticism and misinformation need to be counteracted by health education and counseling."

Naunehal was implemented using what the researchers describe as "a particularly cost-effective model with an optimal number of targeted, appropriately timed mobile health service visits using essential staff providing immunizations, healthcare services, and nutritional counseling. The added element of community mobilization guaranteed the community was aware and receptive, which ensured the efficient usage of the outreach program, thus minimizing costs."

In conclusion: "This relatively low-cost, simplified intervention was effective in reaching marginalized, at-risk populations and reducing key gaps in childhood immunization....It is advisable to scale up and evaluate this strategy at the population level in other conflict-affected contexts to examine the feasibility and effectiveness of increasing immunization coverage in high-transmission settings, especially for polio."