title: Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization card and maternal education.
abstract: OBJECTIVE
  A substantial dropout from the first dose of diphtheria-tetanus-pertussis (DTP1) to the 3rd dose of DTP (DTP3) immunization has been recorded in Pakistan. We conducted a randomized controlled trial to assess the effects of providing a substantially redesigned immunization card, centre-based education, or both interventions together on DTP3 completion at six rural expanded programme on immunization (EPI) centres in Pakistan.
  
  
  METHODS
  Mother-child pairs were enrolled at DTP1 and randomized to four study groups: redesigned card, centre-based education, combined intervention and standard care. 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 period in each study group.
  
  
  RESULTS
  We enrolled 378 mother-child pairs in redesigned card group, 376 in centre-based education group, 374 in combined intervention group and 378 in standard care group. 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 (66%) (crude risk ratio [RR] = 1.7; 95% CI = 1.5, 2.0), centre-based education group (61%) (RR = 1.5; 95% CI = 1.3, 1.8) and combined intervention group (67%) (RR = 1.7; 95% CI = 1.4, 2.0).
  
  
  CONCLUSIONS
  Improved immunization card alone, education to mothers alone, or both together were all effective in increasing follow-up immunization visits. The study underscores the potential of study interventions' public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system.
authors.affiliation: Department of Epidemiology, University of Alabama, Birmingham, AL, USA. hussain@uab.edu
authors.forename: Hussain R
authors.initials: HR
authors.lastname: Usman
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Rahbar
authors.forename: Sibylle
authors.initials: S
authors.lastname: Kristensen
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
authors.forename: Russell S
authors.initials: RS
authors.lastname: Kirby
authors.forename: Faiza
authors.initials: F
authors.lastname: Habib
authors.forename: Eric
authors.initials: E
authors.lastname: Chamot
mesh_terms: D000293:Adolescent; D000328:Adult; D015721:Diphtheria-Tetanus-Pertussis Vaccine / Q000008:administration & dosage*; D005260:Female; D006266:Health Education / Q000458:organization & administration; D006801:Humans; D007115:Immunization Schedule; D007223:Infant; D007231:Infant, Newborn; D032541:Mass Vaccination / Q000706:statistics & numerical data; D008499:Medical Records; D009035:Mothers / Q000193:education*; D010154:Pakistan; D010352:Patient Dropouts / Q000706:statistics & numerical data; D019035:Rural Health Services / Q000458:organization & administration; D012959:Socioeconomic Factors; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D015721:Diphtheria-Tetanus-Pertussis Vaccine