Pakistan: Household Cost-Benefit Decisions About Immunisation, 2005-2009

Lasbela is one of the focus districts for the Pakistan social audit on devolution (See that project and the focus district scheme). CIET also conducted a randomised controlled cluster trial (RCCT) of evidence-led communications at community level to determine its impact on household decisions about childhood immunisation.
The trial tested the importance of a household cost-benefit equation that decision-makers for children derive from their knowledge, attitudes, social norms, intention, sense of agency and degree of socialization about immunisation. The hypothesis was that this dynamic equation can be influenced by a multi-directional knowledge transfer and, based on this transfer, that people adjust their household cost-benefit equation and their uptake of immunisation.

In 2004-5 CIET conducted a baseline household survey covering 3366 households across the district and focus group discussions with males and females in 32 sample sites. The survey documented the situation in the district regarding knowledge, attitudes, and practices of householders about child immunization, and identified barriers and information imbalances that reduced childhood immunization. The findings indicated that the household cost-benefit equation in Lasbela is dominated by concerns about immediate costs (especially time costs), while parents discount heavily the potential future costs of vaccine-preventable illnesses.

CIET used the findings from this baseline to design a knowledge transfer intervention, applied in randomly selected communities. The intervention consisted of a three-phase discussion of the evidence on the cost benefit equation with gender stratified groups of trusted and active people in each community. The first round shared evidence from the baseline survey. The second round focussed on the costs and benefits of childhood vaccination. The third round led to local action plans, including disseminating the information to all households in the community, and options for sharing transport and childcare costs. Meanwhile, all communities in Lasbela received evidence-based health messages around child health and household hygiene.

CIET measured the impact of the knowledge transfer intervention on changing beliefs of decision-makers for children and, as a consequence, uptake of immunization, through a follow-up survey in 2007. Analysis of the RCCT indicated a doubling of vaccination rates for measles and DPT in the 12-23 month age group in the intervention communities, compared with control communities, after adjusting for clustering and baseline findings.

The trial protocol was published in 2005. (See: Andersson N, Cockcroft A, Ansari N, Omer K, Losos J, Ledogar RJ, Tugwell P and Shea B. Household cost-benefit equations and sustainable universal childhood immunization: a randomised cluster controlled trial in south Pakistan [ISRCTN12421731]. BMC-Public Health 2005,5:72 )
The findings from the baseline survey are described in the Lasbela District Government social audit 2005.
Five articles describing the findings of the baseline survey and the RCCT have been published in BMC International Health and Human Rights and can be found at A description of the content of each article can be found here.