ABSTRACT
The need to improve uptake of routine immunizations by mothers using reminder and recall strategies so as to prevent childhood vaccine-preventable diseases is a global public health concern. Globally, about 1.5 million children still die yearly from vaccine-preventable diseases. In Nigeria, 62.8% children are not immunized while 36.4% of children were partially immunized due to poor uptake. The Taraba State W.H.O. reports for 2011-2014 showed hat uptake of routine immunization was less then 50% in 14 out of the 16 L.G.As as about 87.5% of mothers missed their routine immunization appointments. Previous empirical studies have found that reminding and recalling mothers for their immunization appointments improve their rate of immunization uptake but no such studies have been done in Taraba State. The study was designed to find the efficacy of telephone call reminders and recalls in improving uptake of routine immunization services in Taraba State. Five objectives were formulated, five corresponding research questions posed and five hypotheses postulated for verification. A quasi-experimental research design was used for the study. The instruments for data collection were two pre and post-intervention immunization checklists. Reliability test yielded a co-efficient index of 0.72. The population was 1000 while the sample size was 100 mothers of 0-1 year olds coming for routine immunization at the time of the study. Data was analyzed using descriptive statistics, the McNemar’s test and ANCOVA. The major results of the study were that: the total mean rate of uptake for the scheduled visits for the three antigens by the experimental groups pre-intervention was 1.50+0.71 and 2.74+0.44 post-intervention and for the control groups pre-intervention, it was 1.74+0.53 and 1.98+0.62 post intervention; there was a significant difference between the pre and post-intervention uptake of the experimental groups; there was no statistically significant difference between the rate of uptake of majority of the antigens by the control groups in the pre- and post-invention periods; there was a significant difference in the rates of uptake between the experimental and control groups; there was no significant difference between the uptake of the experimental groups in the rural and urban locations; there were no significant difference between the rate of uptake of the experimental and control groups in the rural and urban locations. Recommendations were that effective current communication strategies like telephone calls used to remind and recall mothers to ensure improvement in uptake of routine immunization services in both rural and urban locations.
CHAPTER ONE
INTRODUCTION
Background to the Study
The need to use immunization reminders and recalls for mothers to ensure continued uptake of routine immunization of their infants cannot be over-emphasized. It has been found that immunization reminder and recall system is one of the effective ways of improving immunization uptake rates (Brown, Oluwatosin&Ogundeji, 2015). Immunization has been defined by the Centre for Disease Control (CDC, 2014) as “an act of introducing a vaccine into the body through vaccination to produce immunity to a specific disease. Schuchat& Bell (2008) posited that immunization is aimed at producing immunity to specific diseases and improving control of vaccine preventable communicable diseases thereby preventing their spread. Immunization can also be defined as the use of vaccines through immunization programmes to enable the body to develop immunity so as to resist vaccine-preventable infections and prevent their spread.
There are various types of immunization. These have been identified by Hamm (2015) as including adult immunization, travel immunization, influenza immunization and routine childhood immunization. Routine childhood immunization according to UNICEF (2015) is one of the most cost-effective public health interventions to date against vaccine-preventable diseases (VPDs) as it averts about 2-3 million deaths and disability of children each year. Castillo (2013) also stated that approximately 29 per cent of deaths of under-5 children are preventable through routine immunization. The vaccine-preventable diseases targeted by routine immunization according to Antai (2012), include infantile tuberculosis, diphtheria, pertussis (whooping cough), poliomyelitis, pneumococcal diseases, rotavirus, vitamin A deficiency, measles, yellow fever and cerebro-spinal meningitis.
However, Offit (2014) observed that approximately 1.5 million children still die each year from vaccine-preventable diseases. Also CDC (2013) hinted that polio is still paralyzing children in several African countries and that more than 350,000 cases of measles were reported from around the world in 2011. Balogun, Sekoni, Okafor, Odukoya et al (2012) observed that about 22 per cent of under-five mortality is still caused by vaccine-preventable diseases in Nigeria even close to the end of the 2015 deadline set aside for the achievement of the fourth Millennium Development Goals (MDGs).The possible reasons for the continued prevalence of VPDs as observed by Gilbert (2012) could be that some vaccines used for immunization are less effective and some communicable diseases are unlikely to be controlled by immunization because of pathogen, host or population characteristics. He also observed that some parents could be complacent and this may culminate in low uptake of immunization by them.
The aim of using vaccination routine immunization to avert VPDs may be difficult to achieve if mothers are complacent about their children’s immunization or they do not present their children for immunization which may make their uptake of routine immunization services low. For instance, UNICEF (2013) observed that out of five infants worldwide, nearly 20 per cent still do not receive the three life-saving doses of diphtheria, tetanus and pertussis vaccine due to lack of adequate uptake of vaccines by mothers for their children and this could make the unreached children defenseless against these killer vaccine-preventable diseases. Also, the World Health Organization (WHO, 2015) observed that in 2013, an estimated 21.8 million infants worldwide did not complete their routine immunizations and 21.6million children in the same age group had not been presented to receive the single dose of measles-containing vaccine due to low uptake of immunization services by mothers. UNICEF (2013) stated that one out of every five infants worldwide still did not receive their complete recommended routine immunization doses in a series. Referring to Taraba State, Ophori (2011) observed that their OPV3 uptake rate was the lowest in the country in 2010 (18.75 per cent). This was collaborated by the yearly routine immunization report for the past four (4) years which revealed that majority of the children (87.5 per cent) who started the immunization schedule did not finish them as shown by the high drop-out rates and that majority of the LGAs performed poorly with regards to uptake of immunization services by mothers. This study conceptualizes a poorly-performing LGA as one that their immunization uptake is below 80 per cent.
Uptake of immunization as defined by Oladimeji, Adeyinka and Aimakhu (2008) is “the percentage of the target population that has been vaccinated according to the recommended immunization schedule. It is synonymous with coverage level and level of use of a vaccine by a proportion of the target population in an immunization programme. Referring to the pentavalent vaccine as an example of immunization uptake, Antai (2009) said that uptake would be the percentage of children in the target population who receive the first dose (penta 1) and those who continue to receive up to the third dose (penta 3) in a series. According to him, this is particularly useful as it shows continuity of use. Immunization programs are usually instituted in such ways as to encourage and ensure a continuous uptake of the relevant recommended vaccines. For instance, the World Health Organization (WHO) had initiated and advised the adoption of immunization schedules an aim of ensuring continuous vaccine uptake rates and reduce the impact of vaccine-preventable diseases (Antai, 2009).The routine immunization schedule in Nigeria according to the National Primary Health Care Development Agency – NPHCDA (2014) requires that a mother visits an immunization clinic seven (7) consecutive times and at various intervals of time for her child to be fully immunized. The WHO (2014) stated that following the immunization schedule, a child under one year should receive BacilleCalmette Guerin (BCG), oral polio vaccine(OPV0) and Hepatitis (Hep0) at birth or within 2 weeks of delivery, OPV1 and Pentavalent 1(penta 1) at 6 weeks, OPV2 and Penta 2 at 10 weeks, OPV3 and Penta 3 at 14 weeks, Vitamin A (first dose) at 6months, Measles(first dose), Yellow fever and Conjugate A Cerebro- Spinal Meningitis (CSM) vaccines at 9 months and Measles 2 and Vitamin A (2nd dose) at 12 months. As there are recommended scheduled intervals for routine immunization vaccines to be given, Offit (2014) suggested that to maintain reductions in morbidity and mortality from VPDs, there may be a need to consider the timing and spacing of vaccine doses according to the schedule to ensure continued and appropriate uptake of vaccines. This is because according to him, the right dose of vaccines given at the right interval through the right route generates the optimal immune response. Brown, Oluwatosin and Ogundeji (2015) also added that children could be exposed to the risk of VPDs if they received their routine immunizations untimely or if the schedule is not followed to ensure maximal uptake.
Routine immunization uptake in Nigeria is far from optimal and not equitable (Antai, 2009). According to him, it could be the reason why Nigeria still accounts for half of the deaths from measles in Africa and has the highest prevalence of circulating wild polio virus (WPV) in the world. Ophori, Tula, Azih, Okojie and Ikpo (2014) added that Nigeria has witnessed gradual but consistent reduction in immunization coverage and is among the ten countries in the world that has an immunization uptake rate below the internationally recommended 80 per cent. Dube, Laberge, Guay, Bramadat et al (2013) added that lack of proper uptake of immunization could pose a threat to herd immunity thereby creating room for vaccine-preventable diseases to persist in or return to communities that have inadequate immunization uptake rates. Continued immunization uptake during childhood has been observed by Harvey, Reissland and Mason (2013) to be reliant on mothers’/parental decision-making and subsequent regular attendance to vaccination clinics. Failure to keep to routine immunization schedules or not continuing to attend immunization appointments by mothers has been observed byBalogun, Sekoni, Okafor, Odukoya, Ezeiru, Ogunnowo and Campbell (2012) to have remained a challenge for uptake of RIS globally as their children may be partially immunized or not immunized. For instance, Abdulraheem, Onajole, Jimoh and Oladipo (2011) observed that 62.8 percent of children in Nigeria were not fully immunized and that 33.4 per cent had missed immunization opportunities while36.4 per cent were partially or incorrectly immunized because of problems of uptake. Also, Henry, Bairagi, Finley, Helleringer and Dahir (2011) posited that only about 5.1 percent of all children in Nigeria had received the three recommended doses of polio and many missed the third dose of the pentavalent vaccines probably because they were not presented for their scheduled routine immunizations at the right times by their mothers. These mothers could lack information and ignorant about the right timing and schedules for immunization of their children or they may be complacent and may forget their children’s immunization schedules and may need to be communicated about their children’s scheduled immunization dates. For instance, Abdulraheen et al (2011) found that 2.5 per cent of mothers whose children had partial or incomplete immunization lacked information of the immunization days and they suggested that there is a need to explore effective information strategies that will help ensure that eligible children receive all the needed and recommended vaccines at the appropriate times so as to become fully immunized and to improve the routine immunization uptake rates.
Since previous studies have linked problems of immunization uptake to problems with communication and information to mothers about immunization, Esamgbedo (2012) therefore suggested that it may be necessary to utilize existing information technology and communication (ICT) tools to communicate and relay information especially about immunization appointments to mothers as they could have some efficacy with regards to their immunization uptake rates. Palavuzlar (2011) defined efficacy as the ability of something, e.g. a medicine to produce the intended or desired results. This means that it is the event which follows immediately after an antecedent or cause and could be referred to as the result or consequence or outcome. He also posited that it is synonymous with effectiveness. Williams, Woodward, Majeed and Saxena (2011) posited that communicating with mothers and caregivers about immunization of their children may be effective in improving immunization uptake rates.
Previous studies have also shown that communicating with mothers through reminder systems could have a strong positive effect on demand for immunizations. NaikandJarosz, (2015)found that adopting improvement strategies like the reminder and recall systems especially for preventive care like routine immunization was effective in provision of systematic care and in reduction of missed appointments. Harvey, Reissland and Mason (2015) therefore suggested that since continued uptake of immunization relied on parental or caregivers’ decisions-making for continued attendance at immunization clinics, it could be necessary to adopt improvement strategies targeted at parents like the reminders and recalls.
Litt (2015) defines reminders and recalls as messages to patients or their caregivers stating that recommended immunizations are due soon (reminders) or past due (recall). Reminders and recalls may be necessary for parental/mothers decision-making about attendance to immunization appointments. This is because they may have some efficacy in improving their uptake of immunization. The efficacy of reminders and recalls in the context of this study refers to the power or ability of reminders and recalls to produce desired consequences, results or outcome of improving the uptake of routine immunization services by the mothers that will be used for this study. For instance, Balogun et al (2012) found that the use of innovative approaches through use of new information technologies like mobile phone reminders helped to reach to 20 per cent of the children that were previously being missed for routine immunization services (RIS). Also, Tieney, Yusuf, McMahon, Rusinak, Brien, Massondi and Lieu (2013) found that reminders and recalls information sent by telephone were effective in increasing full child immunization rates and improving uptake of RIS. Brown, Oluwatosin and Ogundeji (2015) also found that the use of mobile phone technology to remind and recall mothers for their children’s immunization dates aided their compliance with and adherence to immunization guidelines. For this study, the efficacy of mobile telephone call reminders and recalls for mothers in terms of improvement in uptake will be interpreted as increase in the proportions of the children of these mothers that were immunized at 6 weeks , at 10 weeks and at14 weeks with penta 1, penta 2 penta 3 and polio 1, polio 2, polio 3 compared with their pre-intervention measure or cut –off mark that will be elicited from the immunization registers when they immunized their last child for the series of the pentavalent and polio vaccines. The choice of intending to use mobile telephone calls as reminders and recalls is that although Nigeria is a developing country, the use of mobile phone technology is high. Brown, Oluwatosin and Ogundeji (2015) observed that almost everybody both in the urban and rural areas use mobile phones to communicate information and important messages. This study will be experimental in nature and the mothers who come for uptake of routine immunization services for their children in both the urban and rural settings will be used as subjects. Since previous studies have found that RIS uptake is low in Nigeria and have recommended improvement of the immunization uptake in Nigeria using communication strategies like reminder and recall systems, identifying the effects or efficacy of mobile telephone call reminders and recalls to mothers in the improvement of uptake of routine immunization services in both the urban and rural settings has therefore become pertinent. This study being an interventional one could therefore provide a platform on which to seek or explore the effectiveness or efficacy of the use of mobile telephone call reminders and recalls for mothers on improvement of uptake of routine immunizations. This efficacy in this study will be measured through at least a 10 per cent difference between the cut –off marks at pretest and the posttest scores of mothers in the experimental and control groups with regards to uptake of routine immunization services in both the urban and rural settings on each appointment date for the routine immunization services that the study is interested in. The question then is: can the of use of mobile telephone call reminders and recalls be effective in improving uptake of routine immunization services in the urban and rural settings of the poor performing LGAs in Taraba State? This is the intent of this study.
Statement of the Problem
Various previous studies have identified and recommended the use of promising strategies like use of reminders and recalls to encourage demand for and improve uptake of routine immunization services by mothers for their children. One of such strategies is the patient reminder and recall systems. Obioha, Ajala and Matobo, (2010) found that use of parental recall and reminders helped to encourage completion of routine immunization schedules of children by mothers. In spite of these efforts and initiatives that have been put in place internationally and nationally to improve demand for RIS and improve their uptake as well as reduce the incidence of VPDs in children, Mohammad (2013) found that demand for routine immunization was still low. For instance, a study by Balogun et al (2012) found that about 22.6million (83 per cent) children worldwide still did not receive the recommended 3 Pentavalent vaccine doses during the first year of life in 2011.
The UNICEF (2013) while stating that immunization coverage rate as a health output indicator has an effect ultimately geared towards monitoring improvement in uptake in the series of immunizations and eventual reduction in VPDs incidence found that one out of every five infants worldwide still did not receive their complete recommended RIS doses in a series. Also, Adebiyi (2013) found that in Sub-Saharan Africa and that in Nigeria, about 8.4 million (38 per cent) started but did not complete their routine immunization series. He also observed that there was a drop in the national uptake for routine immunization vaccines from 74 per cent in 2010 to 69 per cent in 2011 and to 52 per cent in 2012. He pointed out that only about half of the children under one year get access to basic immunization. This could mean that mothers defaulted or dropped out of their children’s immunization schedules. Defaulting or dropping out of the immunization schedule by mothers could lead to partial or non-immunization of children who could be at risk of contracting vaccine-preventable diseases and consequently low uptake of immunization services. Partial or non-immunization of children could predispose children to vaccine-preventable diseases. For instance, Lui, Johnson, Cousenset. al (2013) observed that about 1.5 million children still die yearly from vaccine-preventable diseases. Also Castillo (2013) stated that about 58,000 newborns died from maternal and neonatal tetanus in 2010 and that Measles continues to kill about 430 children each day mainly in Africa and Asia. Curtis (2014) observed Nigeria still remains endemic for polio among 2 other countries (Pakistan and Afghanistan). As at March 20th 2013, Nigeria had reported 9 cases of wild polio virus (WPV) with 3 of them being reported from Taraba state. In terms of defaulting being an antecedent for low coverage, Ophori (2011) observed that OPV3 coverage for Taraba state was the lowest in the country in 2010 (18.75 per cent). This maybe factual because the RIS yearly uptake report submitted by the various health facilities for RIS in Taraba State to WHO Taraba for 2011, 2012, 2013 and 2014 revealed that in almost all the Local Government Areas (LGAs), majority of the mothers of the children (87.5 per cent) who started the immunization schedule defaulted or dropped out and did not complete their recommended immunization schedules (see Appendix 1, 2 3).Balogun et. al (2012) posited that non-attendance or irregular attendance to immunization appointments may lead to low uptake of routine immunization services and this could pose challenge to healthcare managers and providers. Adebiyi (2013) also agree that low uptake of routine immunization by mothers could leave about 3.25 million children un-immunized at 12 months and he therefore warned that this could add to the already existing huge number of susceptible under-fives which at any point may fuel the occurrence and spread of vaccine preventable diseases (VPDs). This could be true as the investigator while working as a field monitor for RIS in Taraba State, observed that fourteen (14) out of the 16 (88 per cent) LGAs reported outbreaks of measles disease.
Some of the identified reasons by Shidende (2013) for mothers defaulting or dropping out and not keeping to their children’s scheduled immunization appointments include among other things, lack of motivation of and poor interpersonal communication with mothers who come for routine immunization. Although RIS are offered, their uptake has been found to be low both in the urban and rural areas of Taraba State. In order to improve uptake of routine immunization services by mothers, immunization experts and researchers have recommended the use reminder systems and ICT strategies like mobile telephone call reminders and recalls to improve immunization uptake .Although previous studies have been done on use of telephone call reminders and recalls to improve uptake of routine immunization by mothers internationally and nationally, to the best knowledge of the researcher, few are intervention studies and none of such studies have been done in Taraba State. Again to the best knowledge of the investigator, no public primary health care providers use or are using mobile telephone call reminders and recalls or in Nigeria and particularly in Taraba State. She therefore finds the need that such a study should be carried out in Taraba State. The pertinent question here therefore is: Would the use of telephone calls to remind and recall mothers of their children’s routine immunization appointments improve uptake of routine immunization services? This study will seek to answer to this question.
Purpose of the Study
This study is designed to explore the efficacy of mobile telephone call reminders and recalls in the improvement of uptake of routine immunization services by mothers in the poor performing LGAs in Taraba State. Specifically, the study intends to:
- ascertain the rate of immunization uptake by mothers in the experimental groups;
- ascertain the rate of immunization uptake by mothers in the control groups;
- determine the difference in the rate of immunization uptake between the experimental and the control groups;
- compare the rate of uptake in the experimental group in the urban with the rate of uptake in the experimental group in the rural setting;
- compare the difference in the rate of immunization uptake between the experimental and control group in the urban with the difference in the rate of uptake between the experimental and control groups in the rural settings;
Research Questions
The following research questions were posed to guide the study:
- what is the rate of immunization uptake of mothers in the experimental groups?
- what is the rate of immunization uptake by mothers in the control groups?
- what is the difference in the rate of immunization uptake between the experimental and the control groups?
- how does the rate of immunization uptake by mothers in the experimental in the urban differ from the rate of immunization uptake of mothers in the experimental group in the rural setting?
- how does the difference in the rate of immunization uptake between the experimental and control groups in the urban differ from that between the experimental and control groups in the rural setting?
Hypotheses
The following hypotheses are formulated to guide the study and will be tested at.05 level of significance.
- There is no significant difference in the rates of immunization uptake by mothers in the experimental groups.
- There is no significant difference in the rates of immunization uptake by mothers in the control groups.
- There is no significant difference in the rate of immunization uptake between the experimental and the control groups.
- There is no significant difference in the rate of immunization uptake by mothers in the experimental in the urban and the rate of uptake of mothers in the experimental group in the rural setting.
- There is no significant difference between the rate of immunization uptake of the experimental and control groups in the urban and the rate of uptake of the experimental and control groups in the rural setting.
Significance of the Study
This study will generate information about the rates of immunization uptake of mothers in the study population in both urban and rural settings in Taraba State. The findings will reveal the difference in rates of immunization uptake among mother s in the different settings or client locations in the target population in Taraba State. The study will also provide information about the effects of use of mobile telephone call reminders and recalls on the determination of the rates of immunization uptake in the different client settings of the target population. Findings from this study could reveal the efficacy of mobile telephone call reminders and recalls in improving the levels of uptake of RIS by mothers in different settings or client locations in the target population in this study. The study may also provide critical baseline data for designing a telephone call reminder/recall intervention for mothers who come for their children’s routine immunization in Taraba State based on their location.
This kind of study will be useful in various ways especially to nurses and midwives, public health personnel and other health policy makers. The findings will also be of immense benefit to governmental and non-governmental agencies like WHO and UNICEF who are interested in monitoring and improving immunization uptake by mothers. It will also be useful to mothers who bring their infants and children for routine immunization. The findings will be useful to other researchers interested in understanding and improving routine immunization uptake especially in Taraba State.
The findings will help sensitize nurses and midwives to new ways of improving immunization uptake. The findings will also be useful in designing the education of nurses and midwives about these technologies that can enhance uptake of routine immunization services by mothers.
Healthcare system policy makers could use the findings as a guide in planning and designing reminder and recall strategies that could assist mothers in both urban and rural settings with the necessary means to achieve the goal of improvement in their routine immunization uptake. This will help reduce the incidence of vaccine-preventable diseases and consequent mortality from them thereby helping to achieve the MDGs 4 goal. Public health professionals could also use the information to organize (work out logistics) and implement trials for the use of telephone call reminders and recalls strategy for improvement in uptake in a larger scale in primary health care facilities in urban and rural areas.
The findings from this study could benefit research and implementation efforts as they could serve as data source for other local, national or international or peer-reviewed studies of immunization uptake. The findings could also expose the area of focus for research with regards to use of reminders and recalls for improvement in uptake of routine immunization. Researchers could also use the study findingsto identify the necessary strategies to improve routine immunization services uptake rates that could be used to tailor interventions in resource-limited environments.
Scopeof the Study
This study will be delimited to mothers of children aged 0-1 year that receive routine immunization services (RIS) in the urban and rural settings/client populations in the selected poorly-performing LGAs for the study. It will also be limited to only the pentavalent and oral polio vaccines currently utilized and listed in the EPI schedule for under 1-year old according to the EPI/FMOH immunization schedule. Such RIS include OPV1, OPV2, OPV3 and the Pentavalent vaccine as a single vaccine, (which contains DPT, Hepatitis B and Hib).
This study will also be delimited use of mobile telephone call reminders and recalls to remind and recall mothers for their children’s up-coming and over-due immunization clinic appointments and to ascertain how these telephone call reminders and recalls for mothers who come for the routine immunizations of their children improve uptake of immunization.
Operational Definition of Terms
The following terms have been defined operationally be used for this study:
Uptake of Routine Immunization Services
This is defined as the percentage of the target population that has been vaccinated according to the recommended immunization schedule. It is synonymous with coverage level and rate of use of the recommended vaccines in the schedule by a proportion of the target population of the mothers in the different client locations who have immunized children previously. The recommended rate of uptake by the WHO for nations is at least 80 per cent.
Low Uptake
Defaulting at least once by a mother or having a drop- out rate (missing) of up to or more than 10 per cent of the vaccines during a previous child’s immunization process in a health facility. This information will be got from the mothers who are presently immunizing a child but have immunized one or more other children before. The information and would be collaborated with the information in the previous immunization registers of the health facilities. Mothers who did not immunize their last child in the health facility but are able to bring their last immunized child’s immunization card showing that she has defaulted will be allowed to participate in the study.
Poor-Performing LGA
This is defined as one that either has an immunization uptake rate less than the recommended 80 per cent for all antigens or who has an immunization drop – out rate equal to or more than 10 per cent.
Improvement in Uptake of Immunization
This is an increase in the proportion or percentage of uptake of vaccines recommended in the schedule for children by the mothers in the different client locations by at least one dose of a vaccine previously missed or by at least 10 per cent above the pre-intervention immunization uptake status of mothers in the intervention groups in each location.
Telephone Reminders
A reminder for the purpose of this study is defined as “a mobile telephone call made to mothers to invite them to return to the health facility for their children’s age-appropriate up-coming immunizations (at one week and at two days) before they are due.
Telephone Recalls
This is a telephone call made to mothers who have defaulted from or missed or dropped out (after two day and after one week) of their child’s scheduled immunizations appointment to encourage or persuade a mother to return back to the immunization clinic to catch up on their child’s recommended/needed immunizations.
Efficacy of Reminders and Recall
This is the ability of the telephone call reminders and recall to cause or bring about an increase in the proportion of uptake of oral polio, pentavalent and pneumococcal vaccine series (OPV/PENTA/PCV 1, 2,3) accessed by mothers at 6 weeks, 10 weeks and at14 weeks in the experimental groups in comparison with the proportion of the same vaccines previously accessed during the last child’s immunizations at the corresponding periods in the different client locations.
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