Ethiopian Journal of Health Development

Endeavors to improve immunization uptake in Ethiopia

Filimona Bisrat — 2019-10-31

In 1980, the Expanded Program on Immunization (EPI) was initiated by the Ministry of Health, with the objective of reaching 90% coverage among children under 1year of age by the year 1990 (1). The vaccination schedule since then has been in accordance with that recommended by WHO for developing countries (2).

Child vaccination coverage and dropout rates in pastoral and semi-pastoral regions in Ethiopia: CORE Group Polio Project implementation areas

Fasil Tessema — 2019-10-31

Background: Vaccination programs are one of the priority health interventions, and all children in every country should be vaccinated. The World Health Organization (WHO) aims for 90% coverage of the Expanded Program on Immunization (EPI) by the age of 12 months. The CORE Group Polio Project (CGPP) Ethiopia implemented interventions in pastoral and semi-pastoral regions to increase routine immunization coverage and support supplemental immunization campaigns.

Objective: Assess vaccination coverage, estimate dropout rates and identify associated factors. Methods: A cross-sectional study using the modified WHO EPI cluster survey method was conducted as part of the mid-term evaluation in 2015 in six pastoral and semi-pastoral zones in Ethiopia. A sample of 600 children age 12 to 23 months was selected, and mothers/caregivers were interviewed at home using face-to-face interviews, supported by mobile data collection using the Open Data Kit (ODK) system. Data were exported from the server, cleaned, and analysed using STATA 12.0.Both descriptive analytical methods were used and p-values less than 0.05 were used to declare statistical significance.

Results: Of the estimated sample, 577 (96.6%) children were included in the analysis. The overall rate of full vaccination was estimated to be 44.0% (21.2% in pastoral areas and 71.6% in semi-pastoral areas). With vaccine specific coverage of 53.7% for Bacillus Calmette-Guérin (BCG); 58.8% for oral polio vaccine 3 (OPV 3); 58.8% for pentavalent 3; 56.3% for OCV 3 and 53.6% for measles. Mothers’/caregivers’ residence, age and education were found to be significant predictors for children not being fully vaccinated, i.e. children of mothers living in pastoralist communities, young age, and with no education were at a significantly higher risk of being not fully vaccinated. Among those children who had at least one vaccine, 20.5% failed to take at least one of the next higher doses. Specifically, among those who took BCG and pentavalent 1, 10.1% and 14.1%, respectively, failed to take the measles vaccination.

Conclusions and recommendations: The proportion of children who were fully vaccinated in pastoral and semipastoral zones was low. Dropout rates for measles, BCG and pentavalent 1 immunization were above the acceptable rate of less than 10%. Therefore, efforts should focus on mobilizing the community to complete all child vaccinations, and community-based approaches with the integration of community volunteers, health extension workers and health center staff should be strengthened so that dropout children can be traced so that they can complete their vaccinations. More information is also required on why mothers/caregivers fail to ensure that their children take all available vaccinations. [Ethiop.J. Health Dev. 2019;33(Special issue):3-9]

Key words: Vaccination coverage, vaccination dropout, pastoralist, semi-pastoralist, CGPP, Ethiopia

Immunization service providers’ knowledge, attitude and practice in primary health care units in pastoral and semipastoral areas of Ethiopia: CORE Group Polio Project

Muluken Asres — 2019-10-31

Background: Adequate knowledge is key for immunization service provision and related practices, such as providing the right vaccine at the right time, keeping vaccines potent, and to prevent vaccine failures. This study was conducted to assess the knowledge, attitude and practices of immunization service providers in primary health care units in pastoral and semi-pastoral areas of Ethiopia.

Methods: A facility-based cross-sectional study was conducted of 1,280 health workers drawn from health centers (233) and health posts (632) in five regions of Ethiopia: Somali, Gambella, Benishangul-Gumuz, Oromiya and SNNPR. Data were collected using a self-administered questionnaire prepared in English and translated into three local languages, and analyzed using STATA version 13.0. Descriptive statistics and binary logistic regression analysis were carried out to determine the magnitude of, and identify associated factors for, knowledge, attitude and practice. A p-value of less than 0.05 was used to declare statistical significance.

Results: Of all health center respondents, 389 (61.3%) had a good knowledge of the vaccination schedule; 403 (63.5%) had poor practices relating to vaccine placement in refrigerators; and 321(54%) had poor attitudes in relation to vaccines and vaccination. With respect to the vaccination schedule, midwives and Health officers/Medical Doctors were 0.28(95% CI: 0.08-0.95) times less knowledgeable than nurses; and health workers with more than five years’ work experience were 2.78 (95% CI: 1.54-5.01) times more knowledgeable than health workers who had three years’ work experience.

Conclusions and recommendations: In this study, gaps were observed in health service providers’ knowledge, attitudes and practices in relation to immunization. Support to address these gaps – through training, supervision, monitoring and other mechanisms should focus on HEWs whose education is less than or equal to grade 12 at health post level, and on midwives and Health Officers (HOs)/MDs at the health center level. Similarly, attention should be given to enhance the vaccine and vaccination knowledge of semi-pastoral health facility service providers. The government, immunization working partners and other responsible bodies should give attention and take corrective measures to use maximum vaccine preventive potency.[Ethiop.J. Health Dev. 2019;33(Special issue):10-15]

Key words: Immunization, Knowledge, Attitude, Practice, Health Worker

Child vaccination timing, intervals and missed opportunities in pastoral and semi-pastoral areas in Ethiopia

Legesse Kidanne — 2019-10-31

Background: Immunization is one of the most powerful and cost-effective public health interventions. Most vaccines in the immunization schedule require two or more doses to trigger adequate immune response; appropriate timing, proper interval between vaccine doses, and completion of all vaccine doses are important to attain optimal protection.

Objective: To evaluate and identify factors associated with the timeliness of vaccine doses; assess the interval between vaccine doses; and identify missed opportunities among children aged 12 to 23 months.

Methods: A cross-sectional descriptive study was conducted that employed the 30 by 10 modified WHO immunization coverage cluster sampling technique. Considering pastoral and semi-pastoral areas, a total of 60 clusters with a sample of 600 children aged 12 to 23 months and mothers/caregivers were included. Data were collected using smartphones loaded with the Open Data Kit (ODK) system and exported to STATA 12.0 for data description and analysis.

Results: The response rate was 97%, with 54.8% of the sample from pastoral areas. About 51% of the respondents were Muslim, 68% had no education, and 67% were aged 30 or above. More than one fifth (21.9%) of children received at least one vaccine dose earlier than the recommended minimum age. Nearly half (47.7%) of children received at least one subsequent dose earlier than an interval of four weeks. The overall rate of missed opportunities was 42.7%, which was higher in pastoral (61.4%) compared to semi-pastoral areas (30.9%) (P <0.001). Children from pastoral areas had a higher rate of missed opportunities compared to children from semipastoral areas (OR=4.05; 95% CI: 2.28-7.22); and children from mothers/caregivers aged 30 or above had a higher rate of missed opportunities than mothers aged <30 (OR=1.89; 95% CI: 1.32-3.13).

Conclusions: The study identified high proportions of children who started vaccination earlier than the recommended age (later for the first dose of Oral Polio Vaccine (OPV0)). In addition, multiple vaccine doses were administered before the minimum interval of four weeks. Children in pastoral areas have higher rate of missed opportunities compare to children in semi pastoralist and pastoralist areas for vaccines with same schedule. Recommendations: Strong interpersonal communication between mothers and vaccination providers is vital for the timely administration of vaccines. Emphasis should be placed on regular supervision and periodic in-service training of health workers to practice timely vaccine commencement, and maintain proper intervals between doses. Immunization service providers should give all the recommended vaccines with same schedule to reduce rate of missed opportunities. [Ethiop .J. Health Dev. 2019; 33(Special issue):16-23]

Key words: Vaccination timing, interval between doses, pastoralist, semi-pastoralist, Ethiopia, CORE Group Polio Project

Immunization service availability and readiness in primary health care in pastoral and semi-pastoral CGPP Ethiopia implementation districts

Tenager Tadesse — 2019-10-31

Background: The availability of immunization services and the readiness of skilled health workers in health institutions to deliver potent vaccines to end users when required to do so are important inputs that contribute to the reduction of child morbidity and mortality from vaccine-preventable diseases (VPDs). Objective: Assess immunization service availability and readiness in primary health care units (PHCUs) in pastoral and semi-pastoral regions of CGPP Ethiopia implementation districts.

Methods: A facility-based cross-sectional survey was employed on 14–23 August 2016 in all health centers (HCs) and three randomly selected health posts (HPs) in each HC catchment area in 85 CGPP implementation districts. An observation checklist was filled in by trained data collectors for all study PHCUs.

Results: Immunization service availability and service delivery, based on 19 tracer items, were assessed in 860 PHCUs in both pastoral and semi-pastoral areas. In total, 92% of the PHCUs reported providing an immunization service. However, only 18.1% of the PHCUs were observed and 32.4% reported providing immunization on the day data were collected. Overall, immunization service readiness was 56.6%: 85% of the HCs and 46.6% of the HPs were ready for immunization service over the study period. The proportion of PHCUs found to have functional refrigerators was 65%.

Conclusions and recommendations: Great variability observed in terms of service readiness among HCs and HPs in this study. All PHCUs should be equipped with functional refrigerators that are regularly maintained; all immunization antigens and schedule immunization services should be available at the PHCUs daily to avoid missed opportunities; cold chain managers/immunization service providers should be given supervisory support to ensure that they record refrigerator temperatures.[Ethiop .J. Health Dev. 2019; 33(Special issue):24-30]

Key words: Service availability, Service readiness, Pastoralist and semi-pastoralist, Hard to reach community

Contribution of plastic bags to the retention of child immunization cards in Gambella Region and Assosa Zone, Benishangul-Gumuz Region, Ethiopia

Muluken Asres — 2019-10-31

Background: Many vaccines are given more than once, at different ages, and in combinations. Parents are expected to retain immunization cardsfor their children, however in Ethiopia, the retention of child immunization cardsis minimal. For example, the 2005 and 2011 Ethiopian Demographic and Health Surveys showed that 37% and 29% of immunization cards, respectively, were retained. The CORE Group Polio Project developed an innovative approach to keeping home vaccination records for a long time and safely, in the form of a plastic bag designed to hold the immunization card. The pilot project for this innovation was held in GambellaRegion and AssosaZone, Benishangul-Gumuz Region since 2015.

Objective: Evaluate the contribution of plastic bagsfor holding and retaining child immunization cards in Gambella Region and Assosa Zone, Benishangul-Gumuz Region.

Methods: The study was a household-based cross-sectional survey and the target population was households with at least one child aged under 2 years who had received at least one vaccination dose. A sample of 239 households (120 from Gambella Region and 119 from Assosa Zone in Benishangul-Gumuz Region) were selected randomly from immunization registration records. Up to 12 kebeles were included from each region, with at least 10 children per kebele. Data were collected using an Amharic language questionnaire and analyzed with STATA version 13.0.

Results: Of all 239 respondents, 139 (58.2%) received the plastic bag for retaining immunization cards, while 100 (41.8%) did not receive the bag. Of the139 respondents who received immunization cards, 125 (89.9%) utilized the plastic bag. Of those that utilized the bags to hold immunization cards, 50.4% were from Gambella Region and 49.6% were from Benishangul-GumuzRegion. A total of 125 (58.7%) respondents were presented with the immunization card inside the plastic bag, and 88 (41.3%) respondents received the immunization card with no accompanying plastic bag. However, of all respondents who received the plastic bag, 14 (10%) did not put the card inside it. The reasons given byrespondents were that it was difficult to put the card inside the plastic bag(seven cases, (58.3%)) and that itwas lost/damaged or used for some other purpose (five cases, (41.7%)).A total of 145(70%) respondents reported thatthey placed the plastic bag that contains the immunization card in a secure place, such as in a box, and 53 (25.6%) hung it ona wall.

Conclusion: In general, there was 89.5% card retention; 90% of respondents utilized the plastic bag, and 88% of mothers said they would advise others to use the plastic bag.[Ethiop .J. Health Dev. 2019; 33(Special issue):31-36]

Key words: Plastic bag, Immunization Card, Retention, Gambella and Benishangul Gumuz

Healthcare workers’ readiness to provide immunization services at primary health care units in pastoral and semipastoral regions in Ethiopia: Core Group Polio Project implementation areas

Filimona Bisrat — 2019-10-31

Background: Ethiopia has been implementing immunization programs for the past four decades. However, coverage remains low, especially in pastoral and semi-pastoral regions. Among the obstacles to achieving immunization targets is the level of health workers’ readiness to provide immunization services, measured in terms of levels of motivation, capacity and involvement.

Objective: To assess the extent of healthcare providers’ readiness to provide immunization services at primary healthcare units in pastoral and semi-pastoral areas of Ethiopia.

Methods: A cross-sectional survey was conducted on a sample of 1,283 healthcare providers involved in immunization services in 233 health centers, and 699 health posts in the health center catchment areas. From five CORE Group Polio Project intervention regions in Ethiopia, interviews were held with personnel in each health center – an Extended Program on Immunization focal person, a midwife, and the medical director or head. From each health post, interviews were held with one health extension worker. Data were collected using a selfadministered questionnaire facilitated by woreda and zonal health and CORE Group staff. The outcome variable of interest, readiness, was measured using three indicator variables – high to very high levels of self-reported motivation and involvement in immunization service provision, and having received at least one immunizationrelated training in the last two years. In addition to health care workers’ background characteristics, where workers were based – in pastoral or semi-pastoral areas – were included as factors for readiness. Data were entered into EpiData and exported to STATA version 12 for analysis. Binary logistic regression was used to identify independent factors associated with readiness, and p<0.05 was used to declare statistical significance.

Results: Among health center respondents, those with a diploma were 2.3 times more likely to be ready compared to those with a first degree. Similarly, nurses and those who claimed higher satisfaction with supportive supervision were 2.1 and 6.2 times more likely to be ready to provide immunization services compared to midwives and those with a medium level of satisfaction, respectively. Among health post staff, being female (AOR=2.2), having more than five years of work experience (AOR=2.2) and having a high level of satisfaction with supportive supervision (AOR=4.5) showed higher readiness levels compared to males, those with less than or equal to two years of service, and those with a medium level of satisfaction, respectively.

Conclusions: To ensure health care workers’ readiness to provide immunization services, providing ongoing inservice training and improving supportive supervision, particularly for men in health posts, should be prioritized. [Ethiop .J. Health Dev. 2019; 33(Special issue):37-45]

Key words: Primary healthcare unit, readiness, immunization, health workers, pastoral and semi-pastoral, Ethiopia