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1.  "Just like fever": a qualitative study on the impact of antiretroviral provision on the normalisation of HIV in rural Tanzania and its implications for prevention 
Background
Once effective therapy for a previously untreatable condition is made available, a normalisation of the disease often occurs. As part of a broader initiative to monitor the implementation of the national antiretroviral therapy (ART) programme, this qualitative study investigated the impact of ART availability on perceptions of HIV in a rural ward of North Tanzania and its implications for prevention.
Methods
A mix of qualitative methods was used including semi-structured interviews with 53 ART clinic clients and service providers. Four group activities were conducted with persons living with HIV. Data were analyzed using the qualitative software package NVIVO-7.
Results
People on ART often reported feeling increasingly comfortable with their status reflecting a certain "normalization" of the disease. This was attributed to seeing other people affected by HIV, regaining physical health, returning to productive activities and receiving emotional support from health service providers. Overcoming internalized feelings of shame facilitated disclosure of HIV status, helped to sustain treatment, and stimulated VCT uptake. However "blaming" stigma - where people living with HIV were considered responsible for acquiring a "moral disease" - persisted in the community and anticipating it was a key barrier to disclosure and VCT uptake. Attributing HIV symptoms to witchcraft seemed an effective mechanism to transfer "blame" from the family unit to an external force but could lead to treatment interruption.
Conclusion
As long as an HIV diagnosis continues to have moral connotations, a de-stigmatisation of HIV paralleling that occurring with diseases like cancer is unlikely to occur. Maximizing synergies between HIV treatment and prevention requires an enabling environment for HIV status disclosure, treatment continuation, and safer sexual behaviours. Local leaders should be informed and sensitised and communities mobilised to address the blame-dimension of HIV stigma.
doi:10.1186/1472-698X-9-22
PMCID: PMC2759900  PMID: 19740437
2.  Sex, gender, and health biotechnology: points to consider 
Background
Reproductive technologies have been extensively debated in the literature. As well, feminist economists, environmentalists, and agriculturalists have generated substantial debate and literature on gender. However, the implications for women of health biotechnologies have received relatively less attention. Surprisingly, while gender based frameworks have been proposed in the context of public health policy, practice, health research, and epidemiological research, we could identify no systematic framework for gender analysis of health biotechnology in the developing world.
Discussion
We propose sex and gender considerations at five critical stages of health biotechnology research and development: priority setting; technology design; clinical trials; commercialization, and health services delivery.
Summary
Applying a systematic sex and gender framework to five key process stages of health biotechnology research and development could be a first step towards unlocking the opportunities of this promising science for women in the developing world.
doi:10.1186/1472-698X-9-15
PMCID: PMC2726121  PMID: 19622163
3.  Household exposure to violence and human rights violations in western Bangladesh (II): history of torture and other traumatic experience of violence and functional assessment of victims 
Background
Organised crime and political violence (OPV) and human rights violations have marred Bangladesh history since 1971. Little is known about the consequences for the oppressed population. This study describes the patterns of OPV and human rights violations in a disturbed area of Bangladesh and assesses the physical, emotional and social functioning of victims.
Methods
A total of 236 of selected participants in a household survey in Meherpur district were recruited for a detailed study. Interviews and physical examinations were used to obtain information about history of torture and other cruel, inhuman or degrading treatment or punishment (TCIDTP), and about injuries, pain frequency and intensity. Handgrip strength and standing balance performance were measured. The "WHO-5 Well-being" scale was used to assess the subjective emotional well-being of study participants.
Results
The majority of the reported cases of TCIDTP occurred in 2000-2008, 51% of incidents occurred during winter; 32.0% between 20:00 and midnight. Police involvement was reported in 75% of cases. Incidents took place at victims' homes (46.7%), or at the police station, military camp, in custody or in prison (21.9%). Participants experienced 1-10 TCIDTP methods and reported 0-6 injury locations on their bodies; 77.5% reported having at least two injuries. Less than half of the participants were able to stand on one leg for 30 seconds. Only 7.5% of males aged 25-44 had handgrip strength in both hands exceeding average values for healthy people at the same age. Over 85% of participants scored low (<13) on the 25-point "WHO-5 Well-being" scale. The number of years since the TCIDTP event, pain frequency, the need to quit a job to take care of an injured family member, political involvement, personal conflicts and the fear of neighbourhood violence strongly affected emotional well-being. Good emotional well-being correlated with increased political and social participation.
Conclusion
A detailed picture of characteristics of the victimisation is presented. The participants showed poor emotional well-being and reduced physical capacity. The results indicated that the simple and rapid method of assessment used here is a promising tool that could be used to monitor the quality and outcome of rehabilitation.
doi:10.1186/1472-698X-9-31
PMCID: PMC2796639  PMID: 19943932
4.  Reliability and validity of the Student Perceptions of School Cohesion Scale in a sample of Salvadoran secondary school students 
Background
Despite a growing body of research from the United States and other industrialized countries on the inverse association between supportive social relationships in the school and youth risk behavior engagement, research on the measurement of supportive school social relationships in Central America is limited. We examined the psychometric properties of the Student Perceptions of School Cohesion (SPSC) scale, a 10-item scale that asks students to rate with a 5-point Likert-type response scale their perceptions of the school social environment, in a sample of public secondary school students (mean age = 15 years) living in central El Salvador.
Methods
Students (n = 982) completed a self-administered questionnaire that included the SPSC scale along with measures of youth health risk behaviors based on the Center for Disease Control and Prevention's Youth Risk Behavior Survey. Exploratory factor analysis was used to assess the factor structure of the scale, and two internal consistency estimates of reliability were computed. Construct validity was assessed by examining whether students who reported low school cohesion were significantly more likely to report physical fighting and illicit drug use.
Results
Results indicated that the SPSC scale has three latent factors, which explained 61.6% of the variance: supportive school relationships, student-school connectedness, and student-teacher connectedness. The full scale and three subscales had good internal consistency (rs = .87 and α = .84 for the full scale; rs and α between .71 and .75 for the three subscales). Significant associations were found between the full scale and all three subscales with physical fighting (p ≤ .001) and illicit drug use (p < .05).
Conclusion
Findings provide evidence of reliability and validity of the SPSC for the measurement of supportive school relationships in Latino adolescents living in El Salvador. These findings provide a foundation for further research on school cohesion and health risk behavior in Latino adolescents living in the U.S. and other Latin American countries.
doi:10.1186/1472-698X-9-30
PMCID: PMC2789705  PMID: 19939259
5.  Household exposure to violence and human rights violations in western Bangladesh (I): prevalence, risk factors and consequences 
Background
The ruling parties in Bangladesh have systematically used violence against political opponents and criminals. It is essential to 1) determine the magnitude and burden of organised crime and political violence (OPV) and human rights violations in the affected community, and to 2) identify the risk factors and key indicators for developing effective health intervention and prevention measures.
Methods
The population-based study consisted of two parts: a household survey and OPV screening at mobile clinics (presented in Part II). A cross-sectional, multistage cluster household survey was conducted in the Meherpur district in February-March 2008; 22 clusters with a sample size of 1,101 households (population of 4,870) were selected.
Results
Around 83% of households reported being exposed to at least two categories of OPV or human rights violations: 29% reported that the family members had been arrested or detained; 31% reported torture or other cruel, inhuman or degrading treatment or punishment. Crude mortality rate was 17.9/1,000 and under 5 mortality rate was 75/1,000. The annual injury rate was 36%, lifetime experience of violence-related injury was 50%, and pain experience within 2 weeks was reported by 57%. Over 80% of the population over 35 years old complained of pain. High prevalence of injury, lifetime experience of OPV-related injury and pain complaints are related to the level of exposure to OPV and human rights violations. A financial burden was imposed on families with an injured person. A geographical variation was revealed regarding reports of torture and lifetime experience of violence-related injury. A combination of individual, relational, community and societal factors, including variables such as political party affiliation, conflict with other families, household income and residential area, affected the risk of victimisation in the household. The odds ratio for reporting extrajudicial execution of a family member was 9.22 for Awami League supporters, 9.15 for Bangladesh Nationalist Party supporters; and 3.97 for Jamaat-e-Islami Party supporters compared with families with no political involvement.
Conclusion
The level of violence and human rights violations is high. The affected population suffers from violence-related injuries and traumas, which could be a factor contributing to poverty. Victimisation is not random.
doi:10.1186/1472-698X-9-29
PMCID: PMC2790439  PMID: 19930589
6.  The role of community health workers in improving child health programmes in Mali 
Background
Mortality of children under the age of five remains one of the most important public health challenges in developing countries. In rural settings, the promotion of household and community health practices through community health workers (CHWs) is among the key strategies to improve child health. The objective of this study was to assess the performance of CHWs in the promotion of basic child heath services in rural Mali.
Methods
A community-based cross-sectional survey was undertaken using multi-stage cluster sampling of wards and villages. Data was collected through questionnaires among 401 child-caregivers and registers of 72 CHWs.
Results
Of 401 households suppose to receive a visit by a CHW, 219 (54.6%; confidence interval 95%; 49.6-59.5) had received at least one visit in the last three months before the survey. The mother is the most important caregiver (97%); high percentage being illiterate. Caregivers treat fever and diarrhoea with the correct regimen in 40% and 11% of cases respectively. Comparative analysis between households with and without CHW visits showed a positive influence of CHWs on family health practices: knowledge on the management of child fever (p = < 0.001), non-utilization of antibiotics in home treatment of diarrhoea (p = 0.003), presence of cloroquine in the household (p = 0.002), presence (p = 0.001) and use (p = < 0.001) of bed nets. A total of 27 (38%) CHWs had not received supervision at all, against 45 (63%) who have been followed regularly each month during the last six months.
Conclusion
Continuous training, transport means, adequate supervision and motivation of CHWs through the introduction of financial incentives and remuneration are among key factors to improve the work of CHWs in rural communities. Poor performance of basic household health practices can be related to irregular supply of drugs and the need of appropriate follow-up by CHWs.
doi:10.1186/1472-698X-9-28
PMCID: PMC2782322  PMID: 19903349
7.  The forsaken mental health of the Indigenous Peoples - a moral case of outrageous exclusion in Latin America 
Background
Mental health is neglected in most parts of the world. For the Indigenous Peoples of Latin America, the plight is even more severe as there are no specific mental health services designed for them altogether. Given the high importance of mental health for general health, the status quo is unacceptable. Lack of research on the subject of Indigenous Peoples' mental health means that statistics are virtually unavailable. To illustrate their mental health status, one can nonetheless point to the high rates of poverty and extreme poverty in their communities, overcrowded housing, illiteracy, and lack of basic sanitary services such as water, electricity and sewage. At the dawn of the XXI century, they remain poor, powerless, and voiceless. They remain severely excluded from mainstream society despite being the first inhabitants of this continent and being an estimated of 48 million people. This paper comments, specifically, on the limited impact of the Pan American Health Organization's mental health initiative on the Indigenous Peoples of Latin America.
Discussion
The Pan American Health Organization's sponsored workshop "Programas y Servicios de Salud Mental en Communidades Indígenas" [Mental Health Programs and Services for the Indigenous Communities] in the city of Santa Cruz, Bolivia on July16 - 18, 1998, appeared promising. However, eleven years later, no specific mental health program has been designed nor developed for the Indigenous Peoples in Latin America. This paper makes four specific recommendations for improvements in the approach of the Pan American Health Organization: (1) focus activities on what can be done; (2) build partnerships with the Indigenous Peoples; (3) consider traditional healers as essential partners in any mental health effort; and (4) conduct basic research on the mental health status of the Indigenous Peoples prior to the programming of any mental health service.
Summary
The persistent neglect of the Indigenous Peoples' mental health in Latin America raises serious concerns of moral and human rights violations. Since the Pan American Health Organization' Health of the Indigenous Peoples Initiative 16 years ago, no mental health service designed for them has yet been created.
doi:10.1186/1472-698X-9-27
PMCID: PMC2774659  PMID: 19874588
8.  Barriers to the effective treatment and prevention of malaria in Africa: A systematic review of qualitative studies 
Background
In Africa, an estimated 300-500 million cases of malaria occur each year resulting in approximately 1 million deaths. More than 90% of these are in children under 5 years of age. To identify commonly held beliefs about malaria that might present barriers to its successful treatment and prevention, we conducted a systematic review of qualitative studies examining beliefs and practices concerning malaria in sub-Saharan African countries.
Methods
We searched Medline and Scopus (1966-2009) and identified 39 studies that employed qualitative methods (focus groups and interviews) to examine the knowledge, attitudes, and practices of people living in African countries where malaria is endemic. Data were extracted relating to study characteristics, and themes pertaining to barriers to malaria treatment and prevention.
Results
The majority of studies were conducted in rural areas, and focused mostly or entirely on children. Major barriers to prevention reported included a lack of understanding of the cause and transmission of malaria (29/39), the belief that malaria cannot be prevented (7/39), and the use of ineffective prevention measures (12/39). Thirty-seven of 39 articles identified barriers to malaria treatment, including concerns about the safety and efficacy of conventional medicines (15/39), logistical obstacles, and reliance on traditional remedies. Specific barriers to the treatment of childhood malaria identified included the belief that a child with convulsions could die if given an injection or taken to hospital (10/39).
Conclusion
These findings suggest that large-scale malaria prevention and treatment programs must account for the social and cultural contexts in which they are deployed. Further quantitative research should be undertaken to more precisely measure the impact of the themes uncovered by this exploratory analysis.
doi:10.1186/1472-698X-9-26
PMCID: PMC2782321  PMID: 19852857
9.  The fallacy of coverage: uncovering disparities to improve immunization rates through evidence. Results from the Canadian International Immunization Initiative Phase 2 - Operational Research Grants 
Immunization can and does save lives. However, the presence of vaccines does not easily translate into every child being vaccinated, and this is what the studies in this journal supplement reveal. From South Asia to West Africa,the evidence presented here reveals what we are calling the fallacy of coverage, going beyond uncovering the real vaccination rates to providing evidence on the reasons for the lack of effective coverage.
The evidence for the fallacy of coverage is part of an operational research program entitled the Canadian International Immunization Initiative Phase 2 (CIII2). Through a competitive peer review process, six research grants were awarded to increase access to and enhance immunization services. This journal supplement provides a forum for the presentation of the results of five of the six studies.
The story of the fallacy of coverage is made up of five theme areas of evidence - timeliness of immunization, social and gender inequities, vaccine efficacy, understanding demand side issues to tailor interventions, and national data sets masking actual district level coverage rates - that reveal the discrepancies in immunization coverage rates and the reasons behind these discrepancies. As part of the story, and to turn around the fallacy of coverage, the studies also provide proof of effective and locally relevant solutions.
Policies and funding, while keeping an eye on future diseases, clearly need to maintain and increase support to address existing vaccine-preventable diseases to increase coverage such that by 2015 we can achieve 90% national vaccination coverage and reach the MDG of reducing mortality rates among children under five by two-thirds.The results from the operational research grants of the CIII2 offer some answers on how to reach this goal by demonstrating how locally generated evidence can inform immunization strategies to ensure that children who need to get vaccinated will get vaccinated, and vaccinated on time.
doi:10.1186/1472-698X-9-S1-S1
PMCID: PMC3226229  PMID: 19828053
10.  The role of supportive supervision on immunization program outcome - a randomized field trial from Georgia 
Background
One of the most common barriers to improving immunization coverage rates is human resources and its management. In the Republic of Georgia, a country where widespread health care reforms have taken place over the last decade, an intervention was recently implemented to strengthen performance of immunization programs. A range of measures were taken to ensure that immunization managers carry out their activities effectively through direct, personal contact on a regular basis to guide, support and assist designated health care facility staff to become more competent in their immunization work. The aim of this study was to document the effects of "supportive" supervision on the performance of the immunization program at the district(s) level in Georgia.
Methods
A pre-post experimental research design is used for the quantitative evaluation. Data come from baseline and follow-up surveys of health care providers and immunization managers in 15 intervention and 15 control districts. These data were supplemented by focus group discussions amongst Centre of Public Health and health facility staff.
Results
The results of the study suggest that the intervention package resulted in a number of expected improvements. Among immunization managers, the intervention independently contributed to improved knowledge of supportive supervision, and helped remove self-perceived barriers to supportive supervision such as availability of resources to supervisors, lack of a clear format for providing supportive supervision, and lack of recognition among providers of the importance of supportive supervision. The intervention independently contributed to relative improvements in district-level service delivery outcomes such as vaccine wastage factors and the DPT-3 immunization coverage rate. The clear positive improvement in all service delivery outcomes across both the intervention and control districts can be attributed to an overall improvement in the Georgian population's access to health care.
Conclusion
Provider-based interventions such as supportive supervision can have independent positive effects on immunization program indicators. Thus, it is recommended to implement supportive supervision within the framework of national immunization programs in Georgia and other countries in transition with similar institutional arrangements for health services organization.
Abstract in Russian
See the full article online for a translation of this abstract in Russian.
doi:10.1186/1472-698X-9-S1-S11
PMCID: PMC3226230  PMID: 19828055
11.  Monitoring the performance of the Expanded Program on Immunization: the case of Burkina Faso 
Background
The greatest challenge facing expanded programs on immunization in general, and in Burkina Faso in particular, lies in their capacity to achieve and sustain levels of immunization coverage that will ensure effective protection of children. This article aims to demonstrate that full immunization coverage of children, which is the primary indicator for monitoring national immunization programs, is sufficient neither to evaluate their performance adequately, nor to help identify the broad strategies that must be implemented to improve their performance. Other dimensions of performance, notably adherence to the vaccination schedule and the efficacy of the approaches used to reach all the children (targeting) must also be considered.
Methods
The study was carried out using data from surveys carried out in Burkina Faso: the 1993, 1998 and 2003 Demographic and Health Surveys and the 2003 national Survey of Immunization Coverage. Essentially, we described levels of immunization coverage and their trends according to the indicators considered. Performance differences are illustrated by amplitudes and maximum/minimum ratios.
Results
The health regions' performances vary according to whether they are evaluated on the basis of full immunization coverage or vaccination status of children who have not completed their vaccinations. The health regions encompass a variety of realities, and efforts of substantially different intensity would be required to reach all the target populations.
Conclusion
Decision-making can be improved by integrating a tripartite view of performance that includes full immunization coverage, adherence to the vaccination schedule (timely coverage), and the status of children who are not fully vaccinated. With such an approach, interventions can be better targeted. It provides information on the quality and timeliness of vaccination and identifies the efforts required to meet the objectives of full immunization coverage.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S12
PMCID: PMC3226231  PMID: 19828056
12.  Evaluation of immunization coverage within the Expanded Program on Immunization in Kita Circle, Mali: a cross-sectional survey 
Background
In 1986, the Government of Mali launched its Expanded Program on Immunization (EPI) with the goal of vaccinating, within five years, 80% of all children under the age of five against six target diseases: diphtheria, tetanus, pertussis, poliomyelitis, tuberculosis, and measles. The Demographic and Health Survey carried out in 2001 revealed that, in Kita Circle, in the Kayes region, only 13% of children aged 12 to 23 months had received all the EPI vaccinations. A priority program was implemented in 2003 by the Regional Health Department in Kayes to improve EPI immunization coverage in this area.
Methods
A cross-sectional survey using Henderson's method (following the method used by the Demographic and Health Surveys) was carried out in July 2006 to determine the level of vaccination coverage among children aged 12 to 23 months in Kita Circle, after implementation of the priority program. Both vaccination cards and mothers' declarations (in cases where the mother cannot make the declaration, it is made by the person responsible for the child) were used to determine coverage.
Results
According to the vaccination cards, 59.9% [CI 95% (54.7-64.8)] of the children were fully vaccinated, while according to the mothers' declarations the rate was 74.1% [CI 95% (69.3-78.4)]. The drop-out rate between DTCP1 and DTCP3 was 5.5%, according to the vaccination cards. The rate of immunization coverage was higher among children whose mothers had received the anti-tetanus vaccine [OR = 2.1, CI 95% (1.44-3.28)]. However, our study found no difference associated with parents' knowledge about EPI diseases, distance from the health centre, or socio-economic status. Lack of information was one reason given for children not being vaccinated against the six EPI diseases.
Conclusion
Three years after the implementation of the priority program (which included decentralization, the active search for missing children, and deployment of health personnel, material and financial resources), our evaluation of the vaccination coverage rates shows that there is improvement in the EPI immunization coverage rate in Kita Circle. The design of our study did not, however, enable us to determine the extent to which different aspects of the program contributed to this increase in coverage. Efforts should nevertheless be continued, in order to reach the goal of 80% immunization coverage.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S13
PMCID: PMC3226232  PMID: 19828057
13.  Determinants of parents' reticence toward vaccination in urban areas in Benin (West Africa) 
Background
Despite the efforts of health authorities, vaccination coverage of targeted child populations is still poor in many regions. Parents' reticence has been identified as one cause of this situation. However, there is little data to explain the phenomenon that could support decision-making.
Objective
The objective of the study was to uncover the determinants of this reticence toward vaccination among the religious population of the cities of Parakou and Cotonou in Benin.
Methods
This was an exploratory study using a qualitative survey of 12 pastors and 30 faithful from churches that are vaccination-reticent and a control group of the same number of faithful belonging to other churches, all Christian. Individual and group interviews were carried out in the local language using a pre-established and pre-tested guide. The data collected underwent discourse content analysis focused on specific themes.
Results
Analysis of the data reveals an erroneous perception of child vaccination. Those who are reticent say vaccination goes against the will of God, that it is a poison from the "white witch doctor", and that those who vaccinate their children are committing a sin. Members of the control group argued against this, but without conviction. They adhere to the principle of obedience to authority, a biblical precept invoked when the vaccinators oblige them to vaccinate their children. Other factors were identified that could explain the reticence, such as the tactlessness of the vaccinators, parents' previous experiences and false rumours about vaccination.
Conclusion
The reasons for reticence are mainly related to parents' beliefs in religious principles that are sometimes poorly understood. To limit the spread of this phenomenon, more detailed information and negotiation between the health authorities and the pastors of these churches are essential.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S14
PMCID: PMC3226233  PMID: 19828058
14.  System-level determinants of immunization coverage disparities among health districts in Burkina Faso: a multiple case study 
Background
Despite rapid and tangible progress in vaccine coverage and in premature mortality rates registered in sub-Saharan Africa, inequities to access remain firmly entrenched, large pockets of low vaccination coverage persist, and coverage often varies considerably across regions, districts, and health facilities' areas of responsibility. This paper focuses on system-related factors that can explain disparities in immunization coverage among districts in Burkina Faso.
Methods
A multiple-case study was conducted of six districts representative of different immunization trends and overall performance. A participative process that involved local experts and key actors led to a focus on key factors that could possibly determine the efficiency and efficacy of district vaccination services: occurrence of disease outbreaks and immunization days, overall district management performance, resources available for vaccination services, and institutional elements. The methodology, geared toward reconstructing the evolution of vaccine services performance from 2000 to 2006, is based on data from documents and from individual and group interviews in each of the six health districts. The process of interpreting results brought together the field personnel and the research team.
Results
The districts that perform best are those that assemble a set of favourable conditions. However, the leadership of the district medical officer (DMO) appears to be the main conduit and the rallying point for these conditions. Typically, strong leadership that is recognized by the field teams ensures smooth operation of the vaccination services, promotes the emergence of new initiatives and offers some protection against risks related to outbreaks of epidemics or supplementary activities that can hinder routine functioning. The same is true for the ability of nurse managers and their teams to cope with new situations (epidemics, shortages of certain stocks).
Conclusion
The discourse on factors that determine the performance or breakdown of local health care systems in lower and middle income countries remains largely concentrated on technocratic and financial considerations, targeting institutional reforms, availability of resources, or accessibility of health services. The leadership role of those responsible for the district, and more broadly, of those we label "the human factor", in the performance of local health care systems is mentioned only marginally. This study shows that strong and committed leadership promotes an effective mobilization of teams and creates the conditions for good performance in districts, even when they have only limited access to supports provided by external partners.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S15
PMCID: PMC3226234  PMID: 19828059
15.  Gender inequity and age-appropriate immunization coverage in India from 1992 to 2006 
Background
A variety of studies have considered the affects of India's son preference on gender differences in child mortality, sex ratio at birth, and access to health services. Less research has focused on the affects of son preference on gender inequities in immunization coverage and how this may have varied with time, and across regions and with sibling compositions. We present a systematic examination of trends in immunization coverage in India, with a focus on inequities in coverage by gender, birth order, year of birth, and state.
Methods
We analyzed data from three consecutive rounds of the Indian National Family Health Survey undertaken between 1992 and 2006. All children below five years of age with complete immunization histories were included in the analysis. Age-appropriate immunization coverage was determined for the following antigens: bacille Calmette-Guérin (BCG), oral polio (OPV), diphtheria, pertussis (whooping cough) and tetanus (DPT), and measles.
Results
Immunization coverage in India has increased since the early 1990s, but complete, age-appropriate coverage is still under 50% nationally. Girls were found to have significantly lower immunization coverage (p<0.001) than boys for BCG, DPT, and measles across all three surveys. By contrast, improved coverage of OPV suggests a narrowing of the gender differences in recent years. Girls with a surviving older sister were less likely to be immunized compared to boys, and a large proportion of all children were found to be immunized considerably later than recommended.
Conclusions
Gender inequities in immunization coverage are prevalent in India. The low immunization coverage, the late immunization trends and the gender differences in coverage identified in our study suggest that risks of child mortality, especially for girls at higher birth orders, need to be addressed both socially and programmatically.
Abstract in Hindi
See the full article online for a translation of this abstract in Hindi.
doi:10.1186/1472-698X-9-S1-S3
PMCID: PMC3226235  PMID: 19828061
16.  One size does not fit all: local determinants of measles vaccination in four districts of Pakistan 
Background
Rates of childhood vaccination in Pakistan remain low.There is continuing debate about the role of consumer and service factors in determining levels of vaccination in developing countries.
Methods
In a stratified random cluster sample of census enumeration areas across four districts in Pakistan, household interviews about vaccination of children and potentially related factors with 10,423 mothers of 14,542 children preceded discussion of findings in separate male and female focus groups. Logistic regression analyses helped to clarify local determinants of measles vaccination.
Results
Across the four districts, from 17% to 61% of mothers had formal education and 50% to 86% of children aged 12-23 months had received measles vaccination. Children were more likely to receive measles vaccination if the household was less vulnerable, if their mother had any formal education, if she knew at least one vaccine preventable disease, and if she had not heard of any bad effects of vaccination. Discussing vaccinations in the family was strongly associated with vaccination. In rural areas, living within 5 km of a vaccination facility or in a community visited by a vaccination team were associated with vaccination, as was the mother receiving information about vaccinations from a visiting lady health worker. Focus groups confirmed personal and service delivery obstacles to vaccination, in particular cost and poor access to vaccination services. Despite common factors, the pattern of variables related to measles vaccination differed between and within districts.
Conclusions
Vaccination coverage varies from district to district in Pakistan and between urban and rural areas in any district. Common factors are associated with vaccination, but their relative importance varies between locations. Good local information about vaccination rates and associated variables is important to allow effective and equitable planning of services.
doi:10.1186/1472-698X-9-S1-S4
PMCID: PMC3226236  PMID: 19828062
17.  Increasing the demand for childhood vaccination in developing countries: a systematic review 
Background
Attempts to maintain or increase vaccination coverage almost all focus on supply side interventions: improving availability and delivery of vaccines. The effectiveness and cost-effectiveness of efforts to increase demand is uncertain.
Methods
We performed a systematic review of studies that provided quantitative estimates of the impact of demand side interventions on uptake of routine childhood vaccination. We retrieved studies published up to Sept 2008.
Results
The initial search retrieved 468 potentially eligible studies, including four systematic reviews and eight original studies of the impact of interventions to increase demand for vaccination. We identified only two randomised controlled trials. Interventions with an impact on vaccination uptake included knowledge translation (KT) (mass media, village resource rooms and community discussions) and non-KT initiatives (incentives, economic empowerment, household visits by extension workers). Most claimed to increase vaccine coverage by 20 to 30%. Estimates of the cost per vaccinated child varied considerably with several in the range of $10-20 per vaccinated child.
Conclusion
Most studies reviewed here represented a low level of evidence. Mass media campaigns may be effective, but the impact depends on access to media and may be costly if run at a local level. The persistence of positive effects has not been investigated. The economics of demand side interventions have not been adequately assessed, but available data suggest that some may be very cost-effective.
doi:10.1186/1472-698X-9-S1-S5
PMCID: PMC3226237  PMID: 19828063
18.  Knowledge synthesis of benefits and adverse effects of measles vaccination: the Lasbela balance sheet 
Background
In preparation for a cluster-randomized controlled trial of a community intervention to increase the demand for measles vaccination in Lasbela district of Pakistan, a balance sheet summarized published evidence on benefits and possible adverse effects of measles vaccination.
Methods
The balance sheet listed: 1) major health conditions associated with measles; 2) the risk among the unvaccinated who contract measles; 3) the risk among the vaccinated; 4) the risk difference between vaccinated and unvaccinated; and 5) the likely net gain from vaccination for each condition.
Results
Two models revealed very different projections of net gain from measles vaccine. A Lasbela-specific combination of low period prevalence of measles among the unvaccinated, medium vaccination coverage and low vaccine efficacy rate, as revealed by the baseline survey, resulted in less-than-expected gains attributable to vaccination. Modelled on estimates where the vaccine had greater efficacy, the gains from vaccination would be more substantial.
Conclusion
Specific local conditions probably explain the low rates among the unvaccinated while the high vaccine failure rate is likely due to weaknesses in the vaccination delivery system. Community perception of these realities may have had some role in household decisions about whether to vaccinate, although the major discouraging factor was inadequate access. The balance sheet may be useful as a communication tool in other circumstances, applied to up-to-date local evidence.
doi:10.1186/1472-698X-9-S1-S6
PMCID: PMC3226238  PMID: 19828064
19.  Equity and vaccine uptake: a cross-sectional study of measles vaccination in Lasbela District, Pakistan 
Background
Achieving equity means increased uptake of health services for those who need it most. But the poorest families continue to have the poorest service. In Pakistan, large numbers of children do not access vaccination against measles despite the national government's effort to achieve universal coverage.
Methods
A cross-sectional study of a random sample of 23 rural and 9 urban communities in the Lasbela district of south Pakistan, explored knowledge, attitudes and discussion around measles vaccination. Several socioeconomic variables allowed examination of the role of inequities in vaccination uptake; 2479 mothers provided information about 4007 children aged 10 to 59 months. A Mantel-Haenszel stratification analysis, with and without adjustment for clustering, clarified determinants of measles vaccination in urban and rural areas.
Results
A high proportion of mothers had appropriate knowledge of and positive attitudes to vaccination; many discussed vaccination, but only one half of children aged 10-59 months accessed vaccination. In urban areas, having an educated mother, discussing vaccinations, having correct knowledge about vaccinations, living in a community with a government vaccination facility within 5 km, and living in houses with better roofs were associated with vaccination uptake after adjusting for the effect of each of these variables and for clustering; maternal education was an equity factor even among those with good access. In rural areas, the combination of roof quality and access (vaccination post within 5 km) along with discussion about vaccines and knowledge about vaccines had an effect on uptake.
Conclusion
Stagnating rates of vaccination coverage may be related to increasing inequities. A hopeful finding is that discussion about vaccines and knowledge about vaccines had a positive effect that was independent of the negative effect of inequity - in both urban and rural areas. At least as a short term strategy, there seems to be reason to expect an intervention increasing knowledge and discussion about vaccination in this district might increase uptake.
doi:10.1186/1472-698X-9-S1-S7
PMCID: PMC3226239  PMID: 19828065
20.  Evidence-based discussion increases childhood vaccination uptake: a randomised cluster controlled trial of knowledge translation in Pakistan 
Background
Childhood vaccination rates are low in Lasbela, one of the poorest districts in Pakistan's Balochistan province. This randomised cluster controlled trial tested the effect on uptake of informed discussion of vaccination costs and benefits, without relying on improved health services.
Methods
Following a baseline survey of randomly selected representative census enumeration areas, a computer generated random number sequence assigned 18 intervention and 14 control clusters. The intervention comprised three structured discussions separately with male and female groups in each cluster. The first discussion shared findings about vaccine uptake from the baseline study; the second focussed on the costs and benefits of childhood vaccination; the third focussed on local action plans. Field teams encouraged the group participants to spread the dialogue to households in their communities. Both intervention and control clusters received a district-wide health promotion programme emphasizing household hygiene. Interviewers in the household surveys were blind of intervention status of different clusters. A follow-up survey after one year measured impact of the intervention on uptake of measles and full DPT vaccinations of children aged 12-23 months, as reported by the mother or caregiver.
Results
In the follow-up survey, measles and DPT vaccination uptake among children aged 12-23 months (536 in intervention clusters, 422 in control clusters) was significantly higher in intervention than in control clusters, where uptake fell over the intervention period. Adjusting for baseline differences between intervention and control clusters with generalized estimating equations, the intervention doubled the odds of measles vaccination in the intervention communities (OR 2.20, 95% CI 1.24-3.88). It trebled the odds of full DPT vaccination (OR 3.36, 95% CI 2.03-5.56).
Conclusion
The relatively low cost knowledge translation intervention significantly increased vaccine uptake, without relying on improved services, in a poor district with limited access to services. This could have wide relevance in increasing coverage in developing countries.
Trial registration
ISRCTN12421731.
doi:10.1186/1472-698X-9-S1-S8
PMCID: PMC3226240  PMID: 19828066
21.  Portrait of a lengthy vaccination trajectory in Burkina Faso: from cultural acceptance of vaccines to actual immunization 
Background
The global recognition of vaccination is strongly related to the fact that it has proved in the past able to dramatically reduce the incidence of certain diseases. Nevertheless, reactions regarding the practice of vaccination still vary among communities, affecting the worldwide vaccination coverage. Numerous studies, conducted from varying perspectives, have focused on explaining this active refusal or resistance to vaccination. Although in some cases low immunization coverage has been well explained by active refusal or resistance to vaccination, little is known about the reasons for low coverage where those reactions are absent or play a minor role, especially outside an epidemic context. This study attempts to explain this situation, which is found in the health district of Nouna in Burkina Faso.
Methods
An in-depth ethnographic study was undertaken in the health district of Nouna in an effort to understand, from an anthropological point of view, the logic behind the parental decision-making process regarding the vaccination or non-vaccination of children, in a context where rejection of, and reservations concerning vaccination are not major obstacles.
Results
Three elements emerged from the analysis: the empirical conceptions of childhood diseases, the perceived efficacy of vaccine and the knowledge of appropriate age for vaccination uptake; the gap between the decision-making process and the actual achievement of vaccination; and the vaccination procedure leading to vaccination uptake in the particular context of the health district of Nouna.
Conclusion
The procedures parents must follow in order to obtain vaccination for their children appear complex and constraining, and on certain points discord with the traditional systems of meaning and idioms of distress related to pregnancy, the prevention of childhood diseases and with the cultural matrix shaping decision-making and behaviour. Attention needs to be directed at certain promotional, logistical and structural elements, and at the procedure that must currently be followed to obtain vaccination for a child during routine vaccination sessions, which are currently limiting the active demand for vaccination.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S9
PMCID: PMC3226241  PMID: 19828067
22.  Global immunization: status, progress, challenges and future 
Vaccines have made a major contribution to public health, including the eradication of one deadly disease, small pox, and the near eradication of another, poliomyelitis.Through the introduction of new vaccines, such as those against rotavirus and pneumococcal diseases, and with further improvements in coverage, vaccination can significantly contribute to the achievement of the health-related United Nations Millennium Development Goals.The Global Immunization Vision and Strategy (GIVS) was developed by WHO and UNICEF as a framework for strengthening national immunization programmes and protect as many people as possible against more diseases by expanding the reach of immunization, including new vaccines, to every eligible person.This paper briefly reviews global progress and challenges with respect to public vaccination programmes.
The most striking recent achievement has been that of reduction of global measles mortality from an estimated 750,000 deaths in 2000 down to 197,000 in 2007. Global vaccination coverage trends continued to be positive. In 2007 most regions reached more than 80% of their target populations with three doses of DPT containing vaccines. However, the coverage remains well short of the 2010 goal on 90% coverage, particularly in the WHO region of Africa (estimated coverage 74%), and South-East Asia, (estimated coverage 69%). Elements that have contributed to the gain in immunization coverage include national multi-year planning, district-level planning and monitoring, re-establishment of outreach services and the establishment of national budget lines for immunization services strengthening.
Remaining challenges include the need to: develop and implement strategies for reaching the difficult to reach; support evidence-based decisions to prioritize new vaccines for introduction; strengthening immunization systems to deliver new vaccines; expand vaccination to include older age groups; scale up vaccine preventable disease surveillance; improve quality of immunization coverage monitoring and use the data to improve programme performance; and explore financing options for reaching the GIVS goals, particularly in lower-middle income countries.
Although introduction of new vaccines is important,this should not be at the expense of sustaining existing immunization activities. Instead the introduction of new vaccine introduction should be viewed as an opportunity to strengthen immunization systems, increase vaccine coverage and reduce inequities of access to immunization services.
doi:10.1186/1472-698X-9-S1-S2
PMCID: PMC2762311  PMID: 19828060
23.  Assessment of factors associated with complete immunization coverage in children aged 12-23 months: a cross-sectional study in Nouna district, Burkina Faso 
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.
Methods
A cross-sectional study was undertaken in 41 rural communities and one semi-urban area (urban in the text). Data on 476 children aged 12 to 23 months were analyzed from a representative sample of 489, drawn from the Nouna Health Research Centre's Demographic Surveillance System (DSS) database. The vaccination history of these children was examined. The relationships between their immunization status and social, economic and various contextual variables associated with their parents and households were assessed using Chi square test, Pearson correlation and logistic regression.
Results
The total immunization coverage was 50.2% (CI, 45.71; 54.69). Parental knowledge of the preventive value of immunization was positively related to complete immunization status (p = 0.03) in rural areas. Children of parents who reported a perception of communication problems surrounding immunization had a lower immunization coverage rate (p < 0.001). No distance related difference exists in terms of complete immunization coverage within villages and between villages outside the site of the health centres. Children of non-educated fathers in rural areas have higher rates of complete immunization coverage than those in the urban area (p = 0.028). Good communication about immunization and the importance of availability of immunization booklets, as well as economic and religious factors appear to positively affect children's immunization status.
Conclusion
Vaccination sites in remote areas are intended to provide a greater opportunity for children to access vaccination services. These efforts, however, are often hampered by the poor economic conditions of households and insufficient communication and knowledge regarding immunization issues. While comprehensive communication may improve understanding about immunization, it is necessary that local interventions also take into account religious specificities and critical economic periods. Particular approaches that take into consideration these distinctions need to be applied in both rural and urban settings.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S10
PMCID: PMC2762310  PMID: 19828054
24.  Employment in the Ecuadorian cut-flower industry and the risk of spontaneous abortion 
Background
Research on the potentially adverse effects of occupational pesticide exposure on risk of spontaneous abortion (SAB) is limited, particularly among female agricultural workers residing in developing countries.
Methods
Reproductive histories were obtained from 217 Ecuadorian mothers participating in a study focusing on occupational pesticide exposure and children's neurobehavioral development. Only women with 2+ pregnancies were included in this study (n = 153). Gravidity, parity and frequency of SAB were compared between women with and without a history of working in the cut-flower industry in the previous 6 years. Logistic regression analysis was conducted to assess the relation between SAB and employment in the flower industry adjusting for maternal age.
Results
In comparison to women not working in the flower industry, women working in the flower industry were significantly younger (27 versus 32 years) and of lower gravidity (3.3 versus 4.5) and reported more pregnancy losses. A 2.6 (95% CI: 1.03-6.7) fold increase in the odds of pregnancy loss among exposed women was observed after adjusting for age. Odds of reporting an SAB increased with duration of flower employment, increasing to 3.4 (95% CI: 1.3, 8.8) among women working 4 to 6 years in the flower industry compared to women who did not work in the flower industry.
Conclusion
This exploratory analysis suggests a potential adverse association between employment in the cut-flower industry and SAB. Study limitations include the absence of a temporal relation between exposure and SAB, no quantification of specific pesticides, and residual confounding such as physical stressors (i.e., standing). Considering that approximately half of the Ecuadorian flower laborers are women, our results emphasize the need for an evaluating the reproductive health effects of employment in the flower industry on reproductive health in this population.
doi:10.1186/1472-698X-9-25
PMCID: PMC2765421  PMID: 19814818
25.  Reports of evidence planting by police among a community-based sample of injection drug users in Bangkok, Thailand 
Background
Drug policy in Thailand has relied heavily on law enforcement-based approaches. Qualitative reports indicate that police in Thailand have resorted to planting drugs on suspected drug users to extort money or provide grounds for arrest. The present study sought to describe the prevalence and factors associated with this form of evidence planting by police among injection drug users (IDU) in Bangkok.
Methods
Multivariate logistic regression was used to identify factors associated with evidence planting of drugs by police among a community-based sample of IDU in Bangkok. We also examined the prevalence and average amount of money paid by IDU to police in order to avoid arrest.
Results
252 IDU were recruited between July and August, 2008, among whom 66 (26.2%) were female and the median age was 36.5 years. In total, 122 (48.4%) participants reported having drugs planted on them by police. In multivariate analyses, this form of evidence planting was positively associated with midazolam use (Adjusted Odds Ratio [AOR] = 2.84; 95% Confidence Interval [CI]: 1.58 - 5.11), recent non-fatal overdose (AOR = 2.56; 95%CI: 1.40 - 4.66), syringe lending (AOR = 2.08; 95%CI: 1.19 - 3.66), and forced drug treatment (AOR = 1.88; 95%CI: 1.05 - 3.36). Among those who reported having drugs planted on them, 59 (48.3%) paid police a bribe in order to avoid arrest.
Conclusion
A high proportion of community-recruited IDU participating in this study reported having drugs planted on them by police. Drug planting was found to be associated with numerous risk factors including syringe sharing and participation in government-run drug treatment programs. Immediate action should be taken to address this form of abuse of power reportedly used by police.
doi:10.1186/1472-698X-9-24
PMCID: PMC2770985  PMID: 19811653

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