In the landscape of public health, childhood immunisation stands as a cornerstone of disease prevention, ensuring the well-being of the youngest members of society. In Pakistan, this vital public health intervention has faced considerable challenges, marked by alarmingly low childhood immunisation rates that continue to pose significant risks.

Notably, the country grapples with the persistent challenge of polio, a disease that remains endemic, necessitating concerted efforts to curb its resurgence since 2018 - 41 out of 53 cases reported in 2019 originated from the KP province.

Maternal depression vs childhood immunisation

A 2022 study conducted by Adeline Delavande, Javed Younas, and Basit Zafar in Khyber Pakhtunkhwa (KP) explores the impact of interventions targeting maternal mental health and the provision of information by influencers on the demand for childhood immunisations. Earlier research suggests that vaccine hesitancy among parents, lack of information about the benefits of vaccinations, and the indoctrination of religious beliefs contribute to low childhood immunisation rates. This study, however, takes a novel approach by focusing on family-side constraints, while acknowledging the widespread prevalence of maternal depression in Pakistan.

Maternal depression, a pervasive but underdiagnosed issue affecting a quarter of Pakistani women, emerges as a critical factor influencing immunisation behaviour. Despite its substantial burden, maternal depression remains under-treated, creating a significant gap in mental health support for mothers navigating the challenges of childcare. This research, therefore, takes a pioneering step by intertwining the realms of maternal mental health and childhood immunisations, recognising the interplay between psychological well-being and health-seeking behaviours among mothers.

Motivated by the belief that information interventions can lead to behavioural changes, the study leveraged the potential positive effects of psychological support, short-term mental health support, and visualisation-style interventions. While providing generic information has shown modest impacts on immunisation rates in Pakistan, the study aimed to test the effectiveness of short, cost-effective interventions on both maternal mental health and childhood immunisation rates. The study, hence, hypothesised that psychological support alone positively influences immunisation behaviour, and the combination of information and psychological support enhances this effect.

The study

The intervention, conducted by Gallup Pakistan in KP, involved Psychological First Aid (PFA) and immunisation information delivered via phone calls. The sample comprised 1,800 mothers — with infants one month old or younger — divided into three groups: a control group, a group receiving psychological first aid (PFA), and a group receiving both PFA and immunisation information. The study sought to answer critical questions about the effectiveness of these interventions and their potential to improve vaccination coverage. The primary outcomes of interest included children’s immunisation rates, mothers’ mental health measured by the PHQ9 — a depression symptom questionnaire — and maternal knowledge, expectations, and attitudes related to immunisation.

The intervention design involved a series of phone calls, blending basic support, additional information on immunisations, and psychological techniques such as visualisation and planning. The calls aimed to alleviate mental stress, expand cognitive bandwidth, and encourage mothers to think about the long-term consequences of vaccinating their children. Midway through the study, surveyors collected data on the persistence of the interventions’ effects and understanding the mothers’ willingness to pay for vaccination reminders. At the end of the study, another survey aimed to assess the sustained impact on immunisation rates, maternal knowledge, attitudes, and overall life satisfaction.

Results and findings

Results from the study revealed compelling findings. It was found that psychological first aid positively influenced immunisation behaviour, with additional influencers showing little to no significant added effect. The outcomes also demonstrated improvements in maternal mental health, knowledge scores, and positive changes in expectations related to immunisations. Despite challenges such as attrition rates — a measure of people who leave, voluntarily or involuntarily — the study’s robust research design and balanced baseline characteristics enhanced the reliability of the findings. The results suggest that light-touch phone interventions focusing on maternal mental health and visualisation techniques can effectively promote childhood immunisation in rural Pakistan.

This study underscores a significant step forward in addressing the complex challenges of childhood immunisation in Pakistan. By targeting family-side constraints and integrating psychological support with the provision of information, the research demonstrates a holistic approach to bridging the immunisation gap. The findings underscore the importance of considering maternal mental health and expectations in public health interventions, providing valuable insights for policymakers and practitioners working to enhance childhood immunisation rates not only in Pakistan but potentially in similar contexts globally, by implementing targeted strategies at the government level.

Lessons for policymakers

Firstly, recognising the critical role of maternal mental health in shaping immunisation decisions, policymakers should prioritise the integration of mental health support programs into existing maternal and child healthcare services. This could involve training healthcare professionals to identify and address perinatal depression and anxiety effectively. Establishing accessible and culturally sensitive mental health services, particularly in rural areas, can provide the necessary support to mothers, addressing an often underdiagnosed and undertreated aspect of public health.

In tandem with mental health interventions, the government should invest in comprehensive awareness campaigns aimed at dispelling myths and misconceptions surrounding childhood immunisations. Collaborative efforts with religious leaders, community influencers, and healthcare professionals can help disseminate accurate information, emphasising the safety and benefits of vaccinations. Leveraging mass media, including radio and television, can further amplify these messages, ensuring they reach a broader audience across diverse socioeconomic backgrounds.

Furthermore, the research highlights the potential of leveraging influential figures, such as government officials, doctors, religious leaders, and a role model mother to convey the importance of immunisations. Establishing partnerships with these figures to actively promote and support vaccination programmes can significantly impact public perceptions. This approach could include endorsements, public service announcements, and community engagement initiatives to reinforce the significance of childhood immunisations.

The government should also explore policy measures to ease logistical barriers associated with vaccinations. This includes ensuring the availability of vaccines in remote areas, streamlining vaccination schedules, and providing incentives for timely immunisations. Implementing these measures can contribute to an overall improvement in immunisation rates, fostering a healthier future for Pakistan’s children.

The research findings underscore the importance of multifaceted policy interventions that address maternal mental health, dispel misconceptions, integrate visualisation techniques, leverage influential figures, and streamline logistical processes. However, counselling for improving the mental health of mothers, both prenatal and postnatal, can deliver outstanding results for enhancing immunisation rates of newborns. This one public health intervention goes a long way in not only promoting the lifelong health of children but everything that a healthy body and mind can achieve.

By incorporating these strategies, the Pakistani government can pave the way for a more robust immunisation programme, ultimately safeguarding the well-being of the nation’s youngest citizens and their inclusiveness in the development of a progressive society.

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