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Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
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Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
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Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Study flow diagram.
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Figure 3

Study flow diagram.

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Comparison 1 Health education, Outcome 1 Measles vaccine.
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Analysis 1.1

Comparison 1 Health education, Outcome 1 Measles vaccine.

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Comparison 1 Health education, Outcome 2 DTP3.
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Analysis 1.2

Comparison 1 Health education, Outcome 2 DTP3.

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Comparison 1 Health education, Outcome 3 Received at least 1 vaccine.
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Analysis 1.3

Comparison 1 Health education, Outcome 3 Received at least 1 vaccine.

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Comparison 2 Health education plus redesigned reminder card, Outcome 1 DTP3.
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Analysis 2.1

Comparison 2 Health education plus redesigned reminder card, Outcome 1 DTP3.

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Comparison 3 Household monetary incentive, Outcome 1 Measles.
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Analysis 3.1

Comparison 3 Household monetary incentive, Outcome 1 Measles.

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Comparison 3 Household monetary incentive, Outcome 2 Fully immunised children.
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Analysis 3.2

Comparison 3 Household monetary incentive, Outcome 2 Fully immunised children.

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Comparison 3 Household monetary incentive, Outcome 3 BCG.
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Analysis 3.3

Comparison 3 Household monetary incentive, Outcome 3 BCG.

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Comparison 3 Household monetary incentive, Outcome 4 MMR.
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Analysis 3.4

Comparison 3 Household monetary incentive, Outcome 4 MMR.

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Comparison 3 Household monetary incentive, Outcome 5 DTP1.
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Analysis 3.5

Comparison 3 Household monetary incentive, Outcome 5 DTP1.

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Comparison 4 Home visit, Outcome 1 OPV3.
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Analysis 4.1

Comparison 4 Home visit, Outcome 1 OPV3.

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Comparison 4 Home visit, Outcome 2 Measles.
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Analysis 4.2

Comparison 4 Home visit, Outcome 2 Measles.

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Comparison 5 Regular immunisation outreach, Outcome 1 Fully immunised children.
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Analysis 5.1

Comparison 5 Regular immunisation outreach, Outcome 1 Fully immunised children.

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Comparison 6 Integration of immunisation to other health services, Outcome 1 BCG.
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Analysis 6.1

Comparison 6 Integration of immunisation to other health services, Outcome 1 BCG.

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Comparison 6 Integration of immunisation to other health services, Outcome 2 DTP3.
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Analysis 6.2

Comparison 6 Integration of immunisation to other health services, Outcome 2 DTP3.

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Comparison 6 Integration of immunisation to other health services, Outcome 3 Measles.
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Analysis 6.3

Comparison 6 Integration of immunisation to other health services, Outcome 3 Measles.

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Summary of findings for the main comparison. Community‐based health education for improving childhood immunisation coverage

Population: children aged < 24 months
Setting: Pakistan (2 studies)
Intervention: health education in the community (2 studies)
Comparison: standard care

Outcomes

Anticipated absolute effects (95% CI)*

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Standard care

Health education

DTP3

(Follow‐up: 4‐9 months)

577 per 1000

969 per 1000
(629 to 1000)

RR 1.68
(1.09 to 2.59)

1692
(2 studies)3

⊕⊕⊕⊝
Moderate1,2

*The effect in the 'health education' group (and its 95% CI) was based on the assumed risk in the 'standard care' group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval;DTP3: 3 doses of diphtheria‐tetanus‐pertussis containing vaccines; RR: risk ratio.

GRADE Working Group grades of evidence

High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low.

Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate.

Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high.

Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high.

'Substantially different' implies a large enough difference that it might affect a decision.

1 We rated down by 1 level because we judged the included studies at high risk of bias.

2 We rated down by 1 level because of unexplained heterogeneity of effects across studies, P value < 0.00001, I2 = 68%.

3 Andersson 2009; Owais 2011.

Figuras y tablas -
Summary of findings for the main comparison. Community‐based health education for improving childhood immunisation coverage
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Summary of findings 2. Facility‐based health education plus redesigned reminder card for improving childhood immunisation coverage

Population: children aged 6 weeks

Setting: Pakistan
Intervention: facility‐based health education + redesigned reminder vaccination card
Comparison: standard care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Standard care

Health education plus redesigned card

DTP3

(Follow‐up: 90 days)

470 per 1000

705 per 1000
(569 to 879)

RR 1.50
(1.21 to 1.87)

1502
(2 studies)3

⊕⊕⊝⊝
low1,2

*The effect in the 'health education + redesigned card' group (and its 95% CI) was based on the assumed risk in the 'standard care' group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval;DTP3: 3 doses of diphtheria‐tetanus‐pertussis containing vaccines; RR: risk ratio.

GRADE Working Group grades of evidence

High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low.

Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate.

Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high.

Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high.

'Substantially different' implies a large enough difference that it might affect a decision.

1 We rated down by 1 level because of unexplained heterogeneity of effects across studies; P value = 0.04; I2 = 77%.

2 We rated down by 1 level because we judged the 2 included studies at unclear risk of selection bias and at high risk of performance and detection bias.

3 Usman 2009; Usman 2011.

Figuras y tablas -
Summary of findings 2. Facility‐based health education plus redesigned reminder card for improving childhood immunisation coverage
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Summary of findings 3. Monetary incentives for improving childhood immunisation coverage

Population: children aged < 5 years
Setting: Nicaragua (1 study) and Zimbabwe (1 study)
Intervention: monetary incentives in the form of household cash transfers
Comparison: standard care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Standard care

Monetary incentive

Fully immunised children

(Follow‐up: 13 months to 5 years)

701 per 1000

736 per 1000
(631 to 862)

RR 1.05
(0.90 to 1.23)

1000
(2 studies)2

⊕⊕⊝⊝
low1

*The effect in the 'monetary incentive' group (and its 95% CI) was based on the assumed risk in the 'standard care' group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; DTP3: 3 doses of diphtheria‐tetanus‐pertussis containing vaccines; RR: risk ratio.

GRADE Working Group grades of evidence

High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low.

Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate.

Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high.

Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high.

'Substantially different' implies a large enough difference that it might affect a decision.

1 We rated down by 2 levels because we judged the 2 included studies at high risk of bias.

2Maluccio 2004; Robertson 2013.

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Summary of findings 3. Monetary incentives for improving childhood immunisation coverage
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Summary of findings 4. Home visits for improving childhood immunisation coverage

Population: children aged 12‐18 months

Setting: Ghana
Intervention: home visits
Comparison: standard care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Standard care

Home visits

OPV3
(Follow‐up: 6 months)

73 per 100

89 per 100
(76 to 100)

RR 1.22
(1.07 to 1.39)

419
(1 study)2

⊕⊕⊝⊝
low1

*The effect in the 'home visits' group (and its 95% CI) was based on the assumed risk in the 'standard care' group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OPV3: 3 doses of oral polio vaccine; RR: risk ratio.

GRADE Working Group grades of evidence

High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low.

Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate.

Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high.

Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high.

1 We rated down by 2 levels because the 1 included study was judged to be at high risk of bias.

2Brugha 1996.

Figuras y tablas -
Summary of findings 4. Home visits for improving childhood immunisation coverage
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Summary of findings 5. Immunisation outreach with and without incentives for improving childhood immunisation coverage

Population: children aged 0‐6 months
Setting: India
Intervention: regular immunisation outreach with or without household incentives
Comparison: standard care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Standard care

Immunisation outreach

Fully immunised ‐ regular immunisation outreach only

(Follow‐up: 18 months)

58 per 1000

180 per 1000
(98 to 330)

RR 3.09
(1.69 to 5.67)

1239
(1 study)2

⊕⊕⊝⊝
low1

Fully immunised ‐ regular immunisation outreach + non‐monetary incentive

(Follow‐up: 18 months)

58 per 1000

387 per 1000
(228 to 656)

RR 6.66
(3.93 to 11.28)

1242
(1 study)2

⊕⊕⊝⊝
low1

*The effect in the 'immunisation outreach' group (and its 95% CI) was based on the assumed risk in the 'standard care' group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.

GRADE Working Group grades of evidence

High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low.

Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate.

Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high.

Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high.

'Substantially different' implies a large enough difference that it might affect a decision.

1 We rated down by 2 levels because we judged the 1 included study at high risk of bias.

2 Banerjee 2010.

Figuras y tablas -
Summary of findings 5. Immunisation outreach with and without incentives for improving childhood immunisation coverage
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Summary of findings 6. Integration of immunisation with other health services for improving childhood immunisation coverage in low‐ and middle‐income countries

Population: children aged 0‐23 months
Setting: Mali
Intervention: integration of immunisation services with intermittent preventive treatment of malaria
Comparison: standard care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Standard care

Integration

DTP3
(Follow‐up: 12 months)

602 per 1000

1000 per 1000
(854 to 1000)

RR 1.92
(1.42 to 2.59)

1481
(1 study)2

⊕⊕⊝⊝
low1

*The effect in the 'integration' group (and its 95% CI) was based on the assumed risk in the 'standard care' group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; DTP3: 3 doses of diphtheria‐tetanus‐pertussis containing vaccines; RR: risk ratio.

GRADE Working Group grades of evidence

High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different is low.

Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different is moderate.

Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different is high.

Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different is very high.

'Substantially different' implies a large enough difference that it might affect a decision.

1 We rated down by 2 levels because we judged the 1 included study at high risk of bias.

2 Dicko 2011.

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Summary of findings 6. Integration of immunisation with other health services for improving childhood immunisation coverage in low‐ and middle‐income countries
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Table 1. Interventions to improve vaccination uptake and how they work

Target

Interventions

Purpose of the interventions

Recipients

Communication interventions to inform and educate targeting individuals, groups, communities or providers, or a combination of these through face‐to‐face interaction, use of mass media, printed material, etc

To improve understanding on vaccination; its relevance; benefits and risks of vaccination; where, when, and how to receive vaccine services; and who should receive vaccine services (Willis 2013)

Communication interventions to recall or remind using face‐to‐face interaction, telephone, mail, etc

To remind those who are overdue for vaccination in order to reduce drop‐out rate (Willis 2013)

Communication interventions to teach skills, e.g. parenting skills

To provide people with the ability to operationalise knowledge through the adoption of practical skills (Willis 2013)

Communication interventions to provide support

To provide assistance or advice for consumers (Willis 2013)

Interventions to facilitate decision‐making, e.g. decision aids on vaccination for parents

To assist carers in participating in decision making (Dubé 2013)

Interventions to enable communication through traditional media, internet, etc

To make communication possible (Dubé 2013)

Interventions, including communication, to enhance community ownership, e.g. community dialogues involving traditional and religious rulers

To increase demand for vaccination

To ensure sustainability

To build trust in vaccination and vaccination services

To drive demand for vaccination

Incentives

To reward service uptake; to cover out‐of‐pocket cost

Providers

Training

To improve knowledge on vaccination, to improve skills, to improve attitudes to clients, to reduce missed opportunities for vaccination

Audit and feedback

To ensure quality and client satisfaction with services

Supportive supervision

To ensure quality and maintain standards, to reduce missed opportunities for vaccination

Incentives

To boost morale and enhance performance

Health system

Infrastructural development, e.g. provision of health facilities, provision of road to improve access to health facilities

To ensure access to services

Logistic support

To improve service quality service and so improve utilisation to ensure availability of services

Service delivery, e.g. outreach; home visits; integration of vaccination with other services; guidelines/protocol for vaccination; increased resources

Outreach to improve access to services

Home visits to remind parents about vaccination and identify unimmunised children for immunisation

Integration to encourage vaccine uptake

Guidelines and protocols to ensure quality of services

Improved resources to ensure availability of services

Policy makers

Advocacy for:

development of supporting policies,

increased funding of health services

To promote the development of policies to support vaccine uptake

To increase funding to the health sector
Figuras y tablas -
Table 1. Interventions to improve vaccination uptake and how they work
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Comparison 1. Health education

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Measles vaccine Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

2 DTP3 Show forest plot

5

Risk Ratio (Random, 95% CI)

Subtotals only

2.1 Community‐based education

2

Risk Ratio (Random, 95% CI)

1.68 [1.09, 2.59]

2.2 Facility‐based education

3

Risk Ratio (Random, 95% CI)

1.20 [0.97, 1.48]

3 Received at least 1 vaccine Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected
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Comparison 1. Health education
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Comparison 2. Health education plus redesigned reminder card

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 DTP3 Show forest plot

2

Risk Ratio (Random, 95% CI)

1.50 [1.21, 1.87]
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Comparison 2. Health education plus redesigned reminder card
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Comparison 3. Household monetary incentive

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Measles Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

2 Fully immunised children Show forest plot

2

Risk Ratio (Random, 95% CI)

1.05 [0.90, 1.23]

3 BCG Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

4 MMR Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

4.1 Household monetary incentive

1

Risk Ratio (Random, 95% CI)

0.0 [0.0, 0.0]

4.2 Service‐level monetary incentive

1

Risk Ratio (Random, 95% CI)

0.0 [0.0, 0.0]

4.3 Household + service‐level monetary incentive

1

Risk Ratio (Random, 95% CI)

0.0 [0.0, 0.0]

5 DTP1 Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

5.1 Household monetary incentive

1

Risk Ratio (Random, 95% CI)

0.0 [0.0, 0.0]

5.2 Service‐level monetary incentive

1

Risk Ratio (Random, 95% CI)

0.0 [0.0, 0.0]

5.3 Household + service‐level monetary incentive

1

Risk Ratio (Random, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 3. Household monetary incentive
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Comparison 4. Home visit

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 OPV3 Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

2 Measles Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 4. Home visit
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Comparison 5. Regular immunisation outreach

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Fully immunised children Show forest plot

1

Risk Ratio (Fixed, 95% CI)

Totals not selected

1.1 Regular immunisation outreach only

1

Risk Ratio (Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Regular immunisation outreach + incentive

1

Risk Ratio (Fixed, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 5. Regular immunisation outreach
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Comparison 6. Integration of immunisation to other health services

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 BCG Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

2 DTP3 Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected

3 Measles Show forest plot

1

Risk Ratio (Random, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 6. Integration of immunisation to other health services
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