The resulting information points to the idea that there are more factors at play than simply developing and then providing vaccination doses to developing nations. The action plans that produce better results are paramount to success, and factors of social significance are just as important as or more important than having enough clinicians or clinics to administer the immunizations. The idea that community based and local volunteers would be needed to help administer and do family teaching about immunizations in India is also supported by Prinja, Gupta, Singha & Kumar who stress that in their large trial, associated with timely vaccinations of children in India with the DPT vaccination the results were far better when local volunteers were recruited as the presence of these individuals as well as their supportive education helped individuals better understand the need for their children to get the vaccination (Web-97). Another concept that is raised in the literature as a potential and real barrier to improved urban immunization rates is a special focus on migrant populations and especially new migrants to the area. It is noted by Kusuma, Kumari, Pandav & Gupta that as the overall economic and education levels of the migrant mothers improved over time immunization rates for children improved but new migrants were a particularly vulnerable population (Web-1326). While the primary focus of the above to research traditions stress interpersonal communication with trusted volunteers from the region as the most effective tool in very hard to reach areas Obregon, Chitnis, Morry, Feek, Bates, Galway & Ogden stress that it is usually a combination strategy, with regard to awareness campaigns that is most effective. According to Obregon et al. The research conducted for polio eradication communication; "…illustrates how evidence-based and planned communication strategies -- such as sustained media campaigns, intensive community and social mobilization, interpersonal communication and political and national advocacy combined -- have contributed to reducing polio incidence in these countries" (Web-624). The work goes on to stress that planned communication strategies, including all of those mentioned above help by, "…mobilizing social networks and leaders; creating political will; increasing knowledge; ensuring individual and community-level demand; overcoming gender barriers and resistance to vaccination; and reaching out to the poorest and marginalized populations" (Web-624).

While interpersonal communication may not be the most efficient rate of either education or compliance with immunizations the issue bears a more expansive look. The reason for this is because the research, from past experiments, clearly indicates that at this stage in the game, i.e. when much has been gained with many of the immunization rates the most important group of unimmunized individuals are all part of a marginalized social group. Among these individuals are multiple barriers to access but overall and sense of mistrust for outsiders. This social barrier can be fundamentally overcome by allowing a member of the same said group to participate in education and implementation of immunizations by simply providing appropriate social cues about the importance of immunizations and most importantly from a trusted "inside" voice.

In another article addressing the need to better educate health care providers regarding the implementation of immunization programs an existing system was measured. The system (ISDS) is a visiting supervisory program where visiting supervisors go to clinic locations teach clinicians and support staff proper procedural process and provide corrective action for incorrect procedures. The interventions recur three times and are relatively costly, due in large part to personnel and travel expenses. The work attempts to determine the cost and effectiveness of this system in an attempt to recommend the system be adopted locally, to reduce costs and possibly improve outcomes as effectiveness was rated very high but over half the cost of the ISDS program was associated with personnel and travel expenses (Web-221).

Sahu, Pradhan, Jayachandran & Khan also point out that access is exceedingly important but that as far as India goes there are also several sets of unknowns even when the researchers used due diligence to provide the most factors in their assessment. The researchers note that though the 2010 90-100% immunization rates for tuberculosis, measles, whooping cough, diphtheria and polio will likely go unrealized, "Universal immunization can be achieved by providing services at community level and information about the available services and their benefits to the community. There is a considerable, unexplained variation in the immunization coverage between different communities, even in the most complex model...

We do know that India is unlikely to meet international and national deadlines for the immunization of 90-100% of all children for all the desired disease types and that there is still much administrative work to be done to resolve the issue, with when this goal will be met. We also know that much of the work above is focused on single vaccination types, though there are a few exceptions. We also know that the literature is clear that special attention needs to be paid to small hold-out populations that produce serious risk for low level endemic disease that can cause serious disease outbreaks. We also know that a combined effort utilizing a list of education and communication tools is the most effective manner in which large increases can be seen in vaccination rates. Lastly, the literature is very clear on the fact that local volunteers capable of developing interpersonal communication with marginalized populations are one of the most effective interventions that can be done in India and this is evident in many research studies.
We do not know if the literatures' reflection of single vaccine focused programs are the standard for vaccination. It would seem that a combined vaccination effort would address access and the fact that opportunities for giving a single dose of any one vaccination are limited and therefore a combined effort seems logical. This perception may be a trick of the literature, and not be the case but there is limited mention in the literature of the combined tactic, as is common in developed nations. This also seems to be despite the Indian national interest in a whole range of vaccination standards. Another issue that may be a party to this perception of single vaccine focused campaigns is the fact that many of the programs associated with vaccination that are not administered by the local administrations themselves are supported by non-governmental organizations (NGOs) and other charities who might have a particular disease eradication focus. Administrative focus on this issue seems paramount as opportunities for vaccination, especially in disenfranchised populations seem to be very few and therefore a combined vaccination effort would seem logical. Lastly, though this may not be possible in all areas due to the nature of Indian Education, though very recently the government adopted compulsory free education for all children ages 6-14 (Pokharel Web) a discussion of compulsory immunizations for entrance into school might need to be addressed. At the very least school site mobile clinics may need to be developed and evaluated.

Recommendations

This work discovered a couple of significant missing pieces in a better understanding of the administration and delivery of immunizations in India. First the work clearly illuminates that the literature does not describe combined efforts or multi-viral immunization schedules and visits, and second that the issue of compulsory education entrance immunizations has not been discussed with regard to India. Due to the fact that the first unknown could simply be related to the literature and the fact that most research works are conducted on limited focuses or it could be that some immunization standards are simply single minded, this work will close with a proposal for a research project that looks at the willingness of parents to accept a compulsory immunization policy. The immunization policy would include the five immunization types that the Indian government sees as most essential to meeting high rates of immunizations; tuberculosis, measles, whooping cough, diphtheria and polio (Sahu, Pradhan, Jayachandran & Khan Web-332). The proposed immunization program would be adopted as part of the new compulsory free school programs and clinics would be provided at school or near school to provide immunizations to those who have not had them. I must reiterate that this is a research focused not on actually implementing such a program but a guide for future implementation tactics and policy review. The impetus for this type of research would be to assess the willingness of Indian parents to allow the implementation of such a program, as compulsory vaccination has been one of the major ways that developed nations have achieved such high rates of immunization and maintained them for so long. The work would begin with a review of available literature on compulsory immunization issues in India, has it been proposed, suggested or even put…