All ETDs from UAB

Advisory Committee Chair

Eric Chamot

Advisory Committee Members

Russell Kirby

Sibylle Kristensen

Hossein Rahbar

Sten H Vermund

Document Type


Date of Award


Degree Name by School

Doctor of Public Health (DrPH) School of Public Health


Childhood immunization coverage in Pakistan remains sub-optimal despite universal and free of cost availability of vaccines. Structural impediments to progress may include the immunization card that is hard to read and interpret. A randomized controlled trial was conducted to assess the effect of redesigned immunization card and center-based education to mothers on immunization completion at rural immunization centers in Karachi, Pakistan. Other objectives were to identify the predictors of immunization completion and to identify factors associated with delay at first dose of diphtheria-tetanuspertussis (DTP1). Mother-child units were enrolled from six immunization centers at DTP1 and randomized to four study groups: 378 in redesigned card group, 376 in center-based education group, 374 in combined intervention group, and 378 in standard care group. Each child was followed-up for 90 days to record the dates of DTP2 and DTP3 visits. The study outcome was DTP3 completion by the end of follow-up. By the end of follow-up, 39% of children in standard care group completed DTP3. Compared to this, a significantly higher proportion of children completed DTP3 in redesigned card group (crude Risk Ratio [RR] = 1.7; 95% CI = 1.5, 2.0), center-based education group (RR = 1.5; 95% CI = 1.3, 1.8), and combined intervention group (RR = 1.7; 95% CI = 1.4, 2.0). iv Separate multivariable log binomial regression analysis of 366 mother-child units in standard care group revealed that DTP3 completion was higher among children who were ≤ 60 days old at enrollment, were from households with monthly household income over Rs. 3000 (USD 50), and were living < 10 minutes away from the immunization center. In multivariable logistic regression analysis of enrollment data on 1461 motherchild units, lower education of father, father being unemployed or owned private business, Mohajir ethnicity, and travelling by bus to reach the immunization center were independently associated with delay at DTP1. In conclusion, we found that providing an improved immunization card and center- based education are effective interventions to reduce immunization dropouts. Also, a substantial proportion of rural children in Pakistan are late for DTP1 and more than a half of them fail to return for DTP3.

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