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Meta-Analysis
. 2022 Nov 8;12(11):e061568.
doi: 10.1136/bmjopen-2022-061568.

Use of community engagement interventions to improve child immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Monica Jain  1 , Shannon Shisler  2 , Charlotte Lane  3 , Avantika Bagai  4 , Elizabeth Brown  5 , Mark Engelbert  3
Affiliations
Meta-Analysis

Use of community engagement interventions to improve child immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Monica Jain et al. BMJ Open. .

Abstract

Objective: To support evidence informed decision-making, we systematically examine the effectiveness and cost-effectiveness of community engagement interventions on routine childhood immunisation outcomes in low-income and middle-income countries (LMICs) and identify contextual, design and implementation features associated with effectiveness.

Design: Mixed-methods systematic review and meta-analysis.

Data sources: 21 databases of academic and grey literature and 12 additional websites were searched in May 2019 and May 2020.

Eligibility criteria for selecting studies: We included experimental and quasi-experimental impact evaluations of community engagement interventions considering outcomes related to routine child immunisation in LMICs. No language, publication type, or date restrictions were imposed.

Data extraction and synthesis: Two independent researchers extracted summary data from published reports and appraised quantitative risk of bias using adapted Cochrane tools. Random effects meta-analysis was used to examine effects on the primary outcome, full immunisation coverage.

Results: Our search identified over 43 000 studies and 61 were eligible for analysis. The average pooled effect of community engagement interventions on full immunisation coverage was standardised mean difference 0.14 (95% CI 0.06 to 0.23, I2=94.46). The most common source of risk to the quality of evidence (risk of bias) was outcome reporting bias: most studies used caregiver-reported measures of vaccinations received by a child in the absence or incompleteness of immunisation cards. Reasons consistently cited for intervention success include appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints. The median intervention cost per treated child per vaccine dose (excluding the cost of vaccines) to increase absolute immunisation coverage by one percent was US$3.68.

Conclusion: Community engagement interventions are successful in improving outcomes related to routine child immunisation. The findings are robust to exclusion of studies assessed as high risk of bias.

Keywords: Community child health; PUBLIC HEALTH; Public health.

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Conflict of interest statement

Competing interests: The International Initiative for Impact Evaluation (3ie). Through this grant, 3ie provided funding and technical assistance for seven impact evaluations of community engagement interventions for immunisation as a part of its immunisation evidence programme. This technical assistance included, but was not limited to: reviewing study designs, analysis plans and data collection instruments; advising research teams on how to improve study components and address challenges that arise during the course of the evaluation; and supporting grantees in engaging with stakeholders to promote uptake and use of evidence generated by the evaluations. As members of 3ie staff, authors MJ, AB and ME have all had varying levels of involvement in reviewing deliverables for these evaluations and providing research teams with technical assistance. Several procedural safeguards and transparency measures were put in place to mitigate the risk this conflict of interest imposed. First, all candidate studies, including those funded by 3ie, underwent a rigorous multi‐step screening process, including review at the title, abstract, and full‐text levels. To qualify for inclusion in the SR, a study was judged to meet the inclusion criteria related to study design, outcomes and population by two independent screeners who have reviewed the full text of the study. The 3ie study authors were responsible for assessing whether the studies met the inclusion criteria for community engagement because of the complexity of the framework. However, these authors have no financial interest in this area and have not published any prior reviews on the topic. The remaining study authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
PRISMA flow diagram. PRISMA,. Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Figure 2
Figure 2
Forest plot showing the observed outcomes and the estimate of the random effects model for the impact of community engagement interventions on full childhood immunisation. Note that # (number of) participants is specific to each effect and thus may not reflect the sample size for the full study.
Figure 3
Figure 3
Forest plot showing the observed outcomes and the estimate of the random effects model for the impact of community engagement interventions on DPT3 vaccination. Note that # participants is specific to each effect and thus may not reflect the sample size for the full study.
Figure 4
Figure 4
Forest plot showing the observed outcomes and the estimate of the random effects model for the impact of community engagement interventions on measles vaccination. Note that # participants is specific to each effect and thus may not reflect the sample size for the full study.
See this image and copyright information in PMC

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