Pro-Equity Evidence Map

One systematic review was identified that related to the cost of conducting VPD surveillance.

There is promising evidence that using surveillance/outbreak response data is effective in identifying un/under-immunized populations. Two main use cases were identified: identifying immunity gaps through incorporating surveillance data into mapping, modeling, risk assessment tools, and comparing surveillance data to coverage data; and using surveillance data to inform decision-making and build support. However, evidence is lacking related to the use of surveillance data in the context of routine immunization to identify zero-dose children and missed communities.

Most studies and reports related to surveillance were not context specific; tools and data were gathered and applied across urban, rural, conflict-affected settings. However, a few studies did occur within urban settings, and some specifically mentioned occurring across both rural and urban settings.

Most studies and reports were not context specific; tools and data were gathered and applied across urban, rural, conflict-affected settings. A few studies specifically referenced being implemented in remote, rural settings, or reported being implemented across both urban and rural areas.

One article described an initiative, specifically the Cross-Border Health Initiative in Kenya and Somalia, that involved use of surveillance to identify under/unimmunized people in remote areas also affected by conflict.

Most studies describing the implementation of surveillance initiatives occurred across districts or other sub-national administrative units within countries that most likely contained both urban and rural settings.

Below are all the effectiveness articles identified in the GIS mapping topic. All studies are specific to immunization.

Based on the existing evidence, GIS mapping was classified as a "promising" intervention for identifying zero-dose children and missed communities. Results from eight effectiveness studies found meaningful increases in vaccine coverage following the use of GIS mapping, with five focused on impacts specifically with unvaccinated children or those in vulnerable contexts.

Below are the articles identified that described implementation of GIS mapping activities in urban poor settings. The evidence shows that GIS mapping was often implemented successfully in urban poor areas.

Below are the articles identified that described implementation of GIS mapping activities in remote rural settings. The evidence shows that GIS mapping was often implemented successfully in remote rural areas.

3 reports relevant to GIS mapping in conflict-affected settings were identified. Case studies from the gray literature in particular found positive results linking GIS mapping with improved vaccination coverage, specifically in identifying zero-dose children in migratory, rural, and conflict-affected settings.

The articles below describe implementation of GIS mapping activities in settings not specific to the ERG. The published literature found positive results linking GIS mapping with improved vaccination coverage across a variety of settings, specifically with the implementation of GIS mapping on national and regional levels. Examples of regional and national-scale GIS mapping demonstrate that by aggregating large amounts of data easily, GIS technology can provide a snapshot of coverage rates for an entire region or country—or even more than one country—and can highlight geographic disparities missed using other means.

Six reviews were relevant to CHW and community group collaborations. The first three also contain results related to effectiveness. Several reviews also contain information relevant to implementation. Many of these reviews relate to the Care Group approach, which is one type of CHW and community group collaboration identified in the rapid review.

Four reviews were identified that were relevant to community-based monitoring.

Seven reviews were identified with relevance to integrated campaigns.

Four studies were identified that described the effectiveness of integrated campaigns. Based on results of these studies, integrated campaigns was categorized as a "promising" intervention to reach zero-dose children and missed communities.

One study was identified that described implementing an integrated campaign in an urban setting. This study also described gender-related barriers.

Three studies described the implementation of integrated campaigns in rural settings.

Seven studies described the implementation of integrated campaigns in conflict-affected settings, including two effectiveness studies.

One study was identified that addressed gender-related barriers within integrated campaigns.

Twenty studies, including two effectiveness studies, did not mention specific ERG settings in which the integrated campaigns were implemented.

25 reviews were identified for financial provider incentives. Of note, the financial provider incentives topic was a review of reviews, and therefore only reviews (no individual studies) were eligible.

Based on this review of reviews, evidence is inconclusive regarding whether financial provider incentives, specifically in the form of performance-based initiatives, are effective for reaching zero-dose children and missed communities. Much evidence exists, but variations in approaches and outcomes limit the ability to determine effectiveness. Overall results from reviews were often mixed, conflicting, or uncertain. Evidence is lacking for impact on equity.

Evidence suggests differences in context and programmatic characteristics are critical in determining effectiveness. Financial incentives appear less likely to be effective when suboptimal quality and performance are driven by structural and health system constraints. Impact is more likely when improvements are within the control of providers and/or health facilities. Studies assessing financial incentive effectiveness have typically taken place within public health care systems.

Financial provider incentive interventions were classified as "inconclusive." 22 reviews were identified as relevant to effectiveness of financial provider incentives. The first seven reviews listed below included findings related to the impact of financial provider incentives on immunization outcomes. Results from the reviews on financial incentives are mixed and evidence was often of low certainty. Most called for further evidence on the impact of provider financial incentives on health care service utilization, quality of service provision, and health outcomes. Notably, a vast literature on financial incentives exists, yet the diversity of approaches and the context-specific nature of their implementation limits the ability to make overarching conclusions as to whether this intervention “works.”

Evidence suggests differences in context and programmatic characteristics are critical in determining effectiveness. Financial incentives appear less likely to be effective when suboptimal quality and performance are driven by structural and health system constraints. Impact is more likely when improvements are within the control of providers and/or health facilities. Studies assessing financial incentive effectiveness have typically taken place within public health care systems.

3 reviews were identified for nonfinancial provider incentives. They all found positive results regarding CHW performance and quality of care related to nonfinancial incentives in remote rural and urban poor settings. However, reviews noted limited evidence, including regarding implementation.

Two effectiveness studies were identified on nonfinancial provider incentives. The first study includes outcomes relevant to immunization and found that nonfinancial incentives are a promising intervention for improving health care provider performance and health outcomes, though no improvements were observed in terms of vaccination coverage, while the second is only relevant to other health sectors and found that CHW performance and motivation improved after implementing a program that involved nonfinancial incentives.

The two included effectiveness studies also met the criteria for implementation studies. These articles studied implementation of nonfinancial provider incentives in settings not specific to the ERG.

Sixteen reviews were identified as relevant to understanding how user incentives may impact ​​immunization. While some reviews presented positive significant impacts on immunization, others found impacts were less substantial. Mentions of equity involved reaching hard-to-reach, vulnerable, and underserved groups. Certain articles noted that user incentives can improve immunization outcomes for these groups by addressing barriers, creating opportunities, and tackling basic needs.

Twenty-one studies were identified as eligible that assess the effectiveness of user incentive programs on vaccination coverage. As this review was restricted to studies that included vaccination as an outcome, all included studies are relevant to immunization. Most studies found that user incentives, including financial and nonfinancial incentives across remote rural, urban poor, and conflict settings, had positive effects on vaccine coverage. Many of these studies evaluated the effect of user incentives on populations in vulnerable contexts (e.g., low economic status, poorly performing districts) and found significant increases in reaching these groups with vaccination.

9 articles were identified that studied implementation of user incentives in urban poor settings. User incentive programs were implemented in all Equity Reference Group (ERG) settings, most frequently in urban poor and remote rural areas.

One implementation study was identified in conflict-affected settings.

One implementation study was identified that considered gender-related barriers.

11 articles were identified that studied implementation of user incentives in other settings.

Eight reviews, including systematic reviews and meta-analyses, were identified that are relevant to understanding the effects of women’s groups on child health in vulnerable communities within LMICs. Reviews focused on mother and newborn outcomes such as neonatal mortality, stillbirths, and maternal mortality, as well as breastfeeding, hygiene, and newborn care behaviors. Results were generally positive. Some studies found more significant changes in the most vulnerable groups, while others found equitable changes across different socioeconomic strata.

Based on the existing evidence, interventions involving women's groups were classified as "promising." 23 total effectiveness studies were identified. The first 3 studies listed assessed the effectiveness of interventions involving women's groups on vaccination coverage, with one finding statistically significant positive effects on immunization rates and two finding no statistical differences. The 20 other effectiveness articles assessed the effects of interventions involving women's groups on other child health outcomes and found mostly positive impacts related to neonatal mortality rates and mostly positive or negligible impacts related to other outcomes such as exclusive breastfeeding and wasting and stunting of children.

3 articles were identified that studied implementation of microplanning in urban poor settings. Overall, there was a lack of implementation of interventions involving women's groups in urban poor areas.

32 articles were identified that studied implementation of interventions involving women's groups in remote/rural settings. Studies on the impact of women’s groups most frequently occurred in remote rural settings and among populations in vulnerable contexts, such as poor and young women, indigenous communities, and those with limited access to health care.

5 studies were identified with information specific to gender-related barriers. These studies described how interventions addressed or were designed to address gender-related barriers, such as increasing women’s empowerment. Several studies also noted that existing social structures and structural constraints might have prevented women from participating in women’s groups, potentially limiting their impact. However, there was a general lack of evidence specific to whether interventions affect women's empowerment/address gender-related barriers and the possible impact of empowerment on health-related outcomes.

2 articles were included that studied implementation of interventions involving women's groups in other settings.

Six reviews were relevant to CHW and community group collaborations. The first three also contain results related to effectiveness. Several reviews also contain information relevant to implementation. Many of these reviews relate to the Care Group approach, which is one type of CHW and community group collaboration identified in the rapid review.

Six CHW and community group collaborations were identified across 18 articles (including three reviews) that described their effectiveness, and the evidence is promising. Three main initiatives involved collaborations between CHWs and community groups, including: health extension workers and the Women’s Development Army (WDA) in Ethiopia, community volunteers and health extension workers in the CORE Group Polio Project, and the Care Group (CG) approach in which a CG Promoter (who may be a CHW or CSO staff member) facilitates sessions with groups of volunteer mothers (and sometimes fathers and grandmothers) who learn behavior change methods to promote behavior adoption/change in a specific cohort of households. These interventions were effective at improving maternal and child health outcomes, including increasing polio vaccination coverage in one instance, although many study designs involved observational and quasi-experimental designs.

Two studies among sex workers were implemented within urban areas in India. Another study in Ethiopia specifically mentioned occurring in both urban and rural areas of select districts. Another study occurred in an urban area within the southwest United States.

Fifteen articles described implementation outcomes for studies occurring in rural settings. Implementation in rural settings was most common within this topic.

Three studies involving CHW and community group collaborations were implemented in conflict-affected settings. Two of these three involve the Core Group's Polio Project, which was implemented in both remote, rural regions and border areas in countries with existing conflict. One study was implemented in the Democratic Republic of Congo.

Many studies mentioned how CHW and community group collaborations can address gender-related barriers. These studies typically involved female volunteers and community group members who worked to increase knowledge sharing, empowerment, and strove to remove or address gender-related barriers to accessing care.

A few studies did not specify the ERG setting(s) in which they were implemented. In two instances, two reviews describe implementation of the Care Group approach across multiple settings, not all of which are specified.

Four reviews were identified that were relevant to community-based monitoring.

Twelve studies were included as effectiveness studies for community-based monitoring (CBM). Results from these studies suggest CBM interventions can be effective in improving different aspects of health service delivery (e.g., improved quality, expanded hours of delivery, reduced stock-outs). One study used CBM to monitor immunization provision, and program results suggest CBM may have increased coverage. For these reasons, the intervention was classified as “promising.”

Only two studies described implementing CBM in urban settings. In one study, implementation occurred across both urban and rural settings.

Twelve studies described implementing CBM interventions in rural areas. This was the most frequent setting in which CBM was reported; studies mostly found that implementing CBM in rural areas was feasible and acceptable. One study, Ssebagereka et al., described the costs of implementing CBM using a community score card model in a rural area in Uganda.

Two studies reported on implementation of CBM interventions, specifically using the community score card approach, in fragile/conflict-affected setting, including in Afghanistan and the Democratic Republic of Congo. Both found encouraging results.

Fives studies described implementing CBM in settings where gender-related barriers played a role. Overall, these studies found that CBM initiatives were both impacted by and worked to address gender barriers.

Nine studies reported implementing CBM in other contexts, or the studies did not specify the context in which the intervention occurred. Notable, one study in this group was specific to implementing CMB to monitor vaccination.

2 reviews were identified as eligible in the supportive supervision topic. Neither were specific to immunization.

14 papers were identified as eligible effectiveness studies in the supportive supervision topic. All included immunization-specific information.

Despite the promising results in using supportive supervision to impact quality, the lack of data on use of supportive supervision to inform monitoring and use of data to inform decision-making led to a categorization of “inconclusive” from a monitoring perspective.

1 article was identified that studied implementation of supportive supervision interventions in urban poor settings.

3 implementation studies were included that took place in remote rural settings.

One implementation study was identified in conflict-affected settings.

12 articles were identified that studied implementation of supportive supervision in other settings.

Three reviews were identified that had relevance to targeted surveys, although none were specific to implementation of targeted surveys but described discrete issues, such as sampling methodologies, recall bias, and survey-specific questions. A fourth article, while not a review of the literature, contains a relevant review of a WHO meeting held in 2017 related to the roll-out of the WHO Vaccination Coverage Cluster Survey Reference Manual.

Targeted surveys have been used to monitor both routine immunization and supplemental immunization activities (SIAs) among populations in vulnerable contexts. Studies that compare results from targeted surveys to other data sources show surveys bring accuracy and value, and serve as an important means of informing programming for missed communities. Targeted surveys for monitoring immunization were used mostly in instances where coverage was generally low, or nonexistent (i.e., introduction of a new vaccine or one not routinely administered). Additionally, while studies focused on populations in vulnerable contexts, few focused on zero-dose children or communities. For these reasons, using targeted surveys to monitor immunization programming is categorized as a “promising” approach for addressing equity.

Two studies describe implementation of targeted surveys within urban areas, and another six studies specify that targeted surveys were carried out across both urban and rural areas.

The majority of studies included in this topic were implemented in remote, rural areas. Targeted surveys for monitoring immunization were used mostly in instances where coverage was generally low, or nonexistent (i.e., introduction of a new vaccine or one not routinely administered). Studies mostly described an evaluation of an intervention that used targeted surveys or described their use during SIAs or campaigns.

Two studies report on implementing targeted surveys within conflict-affected areas. Of all ERG settings, this was one of the least reported on for this topic.

Many studies that used targeted surveys either occurred at the district-level, which most likely encompassed both urban and rural areas. Other studies reported results of mathematical modeling without specifying whether data were based on urban or rural settings. Other studies described some aspect of targeted survey implementation, such as addressing recall bias, survey development, etc., that was not specific to a particular ERG setting.

Eleven reviews were identified that were related to social accountability. In part based on findings from these reviews, social accountability was categorized as a "promising" intervention regarding advocacy for zero-dose children and missed communities.

Seven studies (reported across nine studies) were identified that report on the effectiveness of social accountability interventions. None were specific to immunization. Studies were categorized into type of approach, including: 1) rights-based approaches, 2) committees/community groups, 3) non-governmental facilitated models (including community score card initiatives), and 4) multi-sectoral/multi-level interventions.

Two studies, both from Guatemala, described social accountability interventions in urban settings. Three other studies described implementation of social accountability interventions in both urban and rural settings.

Seven studies described implementing social accountability interventions in rural areas and three described implementing interventions in both urban and rural settings.

Three social accountability studies occurred in fragile or conflict-affected settings.

One study was identified that focused specifically on women's role in social accountability interventions, including the identification of barriers and solutions

Five studies occurred in settings where the ERG context was not specified. Often these studies occurred over broad areas, most likely covering both urban and rural locations. One of these studies, located in Zambia, was specific to immunization.

Based on the existing evidence, microplanning, and enhancements made to existing microplanning processes, was classified as a "promising" way to improve identification of and reach to zero-dose children and missed communities. Results from six effectiveness studies found meaningful increases in vaccine coverage or identification of missed communities following the introduction or enhancement of microplanning, often through the addition of digital means. Microplanning also appears to be cost-effective by leading to more efficient use of resources, with some methods being more cost effective than others.

Below are all the effectiveness articles identified in the microplanning topic. The last two studies are a proposed randomized controlled trial protocol and a modeling exercise that demonstrate potential effective uses of microplanning for health service delivery outside of the immunization sector. All other articles are effectiveness studies specific to immunization.

6 articles were identified that studied implementation of microplanning in urban poor settings. The most common ERG priority settings where microplanning interventions were implemented included urban poor and remote rural.

16 articles were identified that studied implementation of microplanning in remote/rural settings. Microplanning interventions were largely successful in remote rural settings and were often implemented as part of supplementary immunization activities (SIAs). There is limited evidence on the effectiveness of microplanning for routine immunization.

One implementation study was identified that considered gender-related barriers.

5 articles were identified that studied implementation of microplanning in other settings.