ABSTRACT
Background:
India initiated Expanded Programme on Immunization (EPI) in 1978 and was renamed to Universal Immunization Programme (UIP) in 1985 and subsequently integrated with National Rural Health Mission (NRHM) in 2005. Many studies have shown that health workers involved in immunization are more concerned towards coverage than the quality of immunization services provided.
Aims and Objectives:
This study aimed to assess the quality of routine immunization services in rural areas of Doiwala Block of Dehradun, Uttarakhand.
Material and Methods:
It was a cross-sectional study conducted for a duration of one year. Study participants included Auxillary Nurse Midwives (ANMs), Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs) and parents/caregivers of children aged 12–23 months residing in that area who had received immunization services on the day of the survey. Institutional ethics committee clearance was obtained before the start of the study. A P value of <0.05 was considered as statistically significant.
Results:
ASHAs at two centres in low-performing centres had never undergone any training for routine immunization but there was no statistically significant difference found between high and low-performing centres (P > 0.05). The most common vaccine not available was the Bacillus Calmette–Guérin (BCG) vaccine. The majority of clients at both high (92%) and low-performing centres (96%) said that they never waited for at least 30 min post-vaccination at the vaccination site for observation.
Conclusion:
The study highlights that most of the ANMs at the immunization centre were having good knowledge and were adequately trained for maintaining cold chains at session sites.
Keywords: Health workers, immunization, quality assessment, vaccination
Introduction
Vaccines are considered as one of the greatest public health achievements of the twentieth century since the first vaccine against smallpox disease was developed by Edward Jenner in 1796.[1] Since then, different vaccines have been developed to provide protection against various infectious diseases such as polio, hepatitis B, tetanus, etc.[2] The World Health Organization (WHO) launched the Expanded Programme on Immunization (EPI) in the year 1974.[3] India initiated the EPI in 1978 with the objective of reducing morbidity and mortality from diphtheria, pertussis, tetanus, poliomyelitis and childhood tuberculosis by providing immunization services to all eligible children and pregnant women by 1990.[4,5] To enhance full immunization coverage of up to 90%, Mission Indradhanush was launched in December 2014.
Patients’ receptivity and uptake are significantly influenced by the communications and behaviour of primary care physicians and family physicians. Studies demonstrate broad agreement on the influence of primary care physicians’ and family physicians’ recommendations on patient uptake among the critical factors influencing vaccine receptivity; this impact is constant across populations and vaccines.[6] Many studies conducted in developing countries have demonstrated that health workers involved in immunization, appear to be more concerned about improving immunization coverage, and therefore quality aspects of immunization services seem to be neglected. Very few studies have covered the quality aspect related to immunization.[7,8]
With this background, the present study was conducted for the assessment of the quality of immunization services in rural areas of Doiwala block in the Dehradun district of Uttarakhand, India.
Materials and Methods
This cross-sectional study was carried out in rural areas of Doiwala block in the Dehradun district of Uttarakhand. Study participants included Auxillary Nurse Midwives (ANMs), Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs) and parents/caregivers of children aged 12–23 months residing in that area who had received immunization services on the day of the survey. The study was conducted after obtaining ethical approval from the institutional ethics committee vide letter No. AIIMS/IEC/21/287.
The relevant data were collected for a period of one year from August 2021 to August 2022.
Informed written consent in the participant’s own language was obtained. A total of 30 clusters in block Doiwala were selected using the cluster sampling method [Figure 1]. Further ranking of these clusters was done based on the two criteria (a) Prevalence of incomplete immunization in each cluster and (b) Number of delayed vaccinations in each cluster (Delayed vaccination = the vaccine administered 28 days after the due date) and five top performing, and five low performing clusters were selected. Following this, a visit to the subcentre or immunization centre which catered to these ten (10) clusters was made. A total of 10 ANMs and 10 ASHAs were interviewed while 5 clients per immunization centre or subcentre, thus, making a total of 50 clients being surveyed in total. Using the following data collection tools, data was collected.
Figure 1.
Flowchart depicting the selection of clusters
-
(A)
Checklist for immunization session observation, vaccines and cold chain equipment.
-
(B)
Pre-designed, pre-tested semi-structured interview schedules for ANM, ASHA and AWWs.
-
(C)
Pre-designed, pre-tested semi-structured client satisfaction interview schedule for the parents/guardians who came for immunization of his/her child at the centre on the day of the survey.
The data were collected and entered in Microsoft Excel 2016 (MS Excel for Windows, Microsoft Corporations, Redmond, Washington, United States) and were analysed using Statistical Package for the Social Sciences (SPSS for Windows, version 25.0, IBM Corporation, Armonk, New York, United States). Appropriate statistical tests were applied and P < 0.05 was considered as statistically significant.
Results
Out of the total immunization sessions planned at the top and bottom performing immunization centres, it was observed that 100% of planned sessions were conducted in all the immunization centres. The difference in the number of sessions conducted in top and bottom-performing centres was mainly attributable to the difference in their population wherein low-performing subcentres catered to areas having a lesser population.
Table 1 shows the comparison between high and low-performing centres in terms of the last training received for cold chain (for ANMs only) or routine immunization (ANMs and ASHAs both). ASHAs at two centres in low-performing centres had never undergone any training for routine immunization. However, the difference between the two was not statistically significant (P > 0.05).
Table 1.
Comparison between high-performing and low-performing centres according to immunization training status of ANMs and ASHAs
| Characteristics | High Performing Centres (5) | Low Performing Centres (5) | U value*, P$ |
|---|---|---|---|
| Number of months since last training on the cold chain or routine immunization by ANM | |||
| Mean±SD | 22±12.07 | 30±25.67 | 12, >0.05 |
| Number of months since last training on routine immunization by ASHA | |||
| Mean±SD | 8.4±7.91 | 09±13.68# | 9, >0.05 |
| Supervision of immunization sessions in the last 3 months | |||
| Number of visits by Higher authority | Once at three out of five | Never | NA |
| Functional Hub Cutter | |||
| Available | 05 (100%) | 04 (80%) | <0.05 (Fisher’s Exact) |
| Not Available | 00 (00%) | 01 (20%) | |
| Functional Weighing Machine | |||
| Available | 04 (80%) | 04 (80%) | 1 (Fisher’s Exact) |
| Not Available | 01 (20%) | 01 (20%) |
* Mann–Whitney U test used; $ P<0.05 significant; #ASHAs at two centres never underwent any training on routine immunization; NA – Not applicable
In the past 3 months preceding the survey, supervision by any higher authority {WHO officer or Lady Health Visitor (LHV) or Medical Officer (MO)} was done at least once in three (3) out of five (5) high-performing centres while no visit was done at any of five (5) low performing centres. Assessment for logistics such as hub cutter and weighing machine showed that all five (100%) high-performing centres had functional hub cutters and four (80%) had functional weighing machines while four (80%) out of five low-performing centres had functional hub cutters and weighing machine, respectively.
Table 2 shows a comparison between high and low-performing centres for cold chain and vaccine logistics management during immunization sessions at the session site. It can be seen that if vaccines were not in use during immunization sessions, they were kept in the vaccine carrier at all of the 10 centres. Assessment done at the time of conduction of immunization session for vaccine carrier showed that at two (40%) high performing and four (04) low-performing centres, ANMs used only three (3) ice packs instead of four (4) while at three (60%) of high performing and one (20%) of low performing centres, ANMs used four (4) ice packs in vaccine carrier during conduction of immunization session.
Table 2.
Comparison of cold chain and vaccine management between high- and low-performing centres
| Characteristics | High-performing centres | Low-performing centres |
|---|---|---|
| Vaccine storage during an immunization session | ||
| Kept in Vaccine carrier (if not in use) | 05 (100%) | 05 (100%) |
| Ice packs in Vaccine Carrier | ||
| 3 | 02 (40%) | 04 (80%) |
| 4 | 03 (60%) | 01 (20%) |
| Vaccines availability at the session site | ||
| All vaccines available | 03 (60%) | 03 (60%) |
| Not available | 02 (40%) | 02 (40%) |
| Logistics management personnel | ||
| ANM | 02 (40%) | 02 (40%) |
| ASHA | 02 (40%) | 02 (40%) |
| AVD@ | 01 (20%) | 01 (20%) |
@AVD – Alternate Vaccine Delivery
Observation for vaccine availability at the session site revealed that at two (40%) of high- and low-performing centres, all vaccines were not available. The most common vaccine which was not available was the Bacillus Calmette–Guérin (BCG) vaccine.
The personnel who were supposed to bring and arrange for logistics at the session site were similar in both high and low-performing centres with ANMs and ASHAs each arranging for logistics at 40% of session sites, respectively, while at 20% of session sites, alternate vaccine delivery (AVD) was responsible for logistics management.
Table 3 shows the comparison of activities that are part of the standard protocol to be performed during immunization sessions at any session site. It can be seen from the table that at only three (60%) of high-performing centres, vaccine assessment (in relation to checking vaccine vial monitor {VVM}, batch no. and expiry date) was done by ANMs while it was done at four (80%) of low performing centres.
Table 3.
Comparison of standard operating procedure followed during the conduction of immunization session
| Characteristics | High-performing centres | Low-performing centres |
|---|---|---|
| Vaccine assessment (checking VVM, Batch no. and Expiry date) | ||
| Yes | 03 (60%) | 04 (80%) |
| No | 02 (40%) | 01 (20%) |
| Time and date of opening on Reconstituted vaccines | ||
| Yes | 04 (80%) | 05 (100%) |
| No | 01 (20%) | 00 (00%) |
| ‘No Recapping’ of Injection | ||
| Followed | 04 (80%) | 02 (40%) |
| Not Followed | 01 (20%) | 03 (40%) |
| Use of hub cutter for cutting syringes post-administration | ||
| Yes | 04 (80%) | 02 (40%) |
| No | 01 (20%) | 03 (60%) |
| Handling of Bio-medical waste generated at the site | ||
| Proper Segregation | 04 (80%) | 05 (100%) |
| No proper segregation | 01 (20%) | 00 (00%) |
| Mother and Child Protection card filled by | ||
| ANM | 04 (80%) | 05 (100%) |
| ASHA | 01 (20%) | 00 (00%) |
| Advise to stay for 30 min post-vaccination | ||
| Yes | 00 (00%) | 01 (20%) |
| No | 05 (100%) | 04 (80%) |
Out of total ten (10) centres, at nine (90%) of the centres, ANMs noted the time and date of opening on the reconstituted vaccine vials.
When assessed for ‘safe injection practices’, with respect to no recapping policy for injection, four (80%) and two (40%) of high and low-performing centres followed this policy and did not recap the injection after loading. Apart from this, the use of a hub cutter for separating needles from syringes post-administration of the vaccine was done at four (80%) high-performing centres and two (40%) low-performing centres.
Bio-medical waste (BMW) generated at the time of the immunization session was properly segregated as per BMW management and handling rules, 2018 at all five (100%) of low-performing centres and four (80%) of high-performing centres, respectively. At one (20%) high-performing centre, all the non-sharp waste generated was disposed of in black bins only without any segregation.
When asked about recording data in mother and child protection (MCP) cards, it was found out that ANMs used to update MCP cards at four and five of high and low-performing centres, respectively, while at one of the high-performing centres, it was filled by the ASHAs. When ANMs were asked whether they advise parents/caregivers to wait for 30 min post-vaccination, it was revealed that at only one (20%) of low-performing centres, ANM was advising to stay for 30 min post-vaccination.
Table 4 shows the assessment of clients towards the quality of immunization services provided at high- and low-performing centres. At both high- and low-performing centres, the distribution was uniform with respect to prior information being provided to them regarding the time and place of immunization (72% responding with yes and 28% with no). 84% (21) and 88% (22) of clients at high and low-performing centres, respectively, were in agreement that immunization providers treated the beneficiary respectfully. All clients (100%) said yes when asked about whether the immunization provider vaccinated the child properly or not and regarding the vaccination card being filled out timely for each vaccine or not.
Table 4.
Client assessment for quality of immunization services
| Characteristics | High-performing centres (N=25) n (%) | Low-Performing centres (N=25) n (%) |
|---|---|---|
| (i) Prior information regarding time and place of immunization given* | ||
| Yes | 18 (72) | 18 (72) |
| No | 07 (28) | 07 (28) |
| (ii) Immunization provider treated the beneficiary respectfully# | ||
| Yes | 21 (84) | 22 (88) |
| No | 04 (16) | 03 (12) |
| (iii) Immunization provider vaccinated the child properly@ | ||
| Yes | 25 (100) | 25 (100) |
| No | 00 (00) | 00 (00) |
| (iv) The vaccination record card was filled timely for each vaccine@ | ||
| Yes | 25 (100) | 25 (100) |
| No | 00 (00) | 00 (00) |
| (v) Understanding which vaccine was given to the child and which diseases will it protect the baby against$ | ||
| Yes | 20 (80) | 19 (76) |
| No | 05 (20) | 06 (24) |
| (vi) Informed regarding scab formation after BCG$ | ||
| Yes | 11 (44) | 08 (32) |
| No | 14 (56) | 17 (68) |
| (vii) Informed regarding the occurrence of fever after Penta or DPT vaccination$ | ||
| Yes | 25 (100) | 25 (100) |
| No | 00 (00) | 00 (00) |
| (viii) Prescription of Paracetamol syrup/tablet given after vaccination (if required)$ | ||
| Yes | 21 (84) | 25 (100) |
| No | 04 (16) | 00 (00) |
| (ix) Information regarding the time of the next scheduled vaccine given$ | ||
| Yes | 22 (88) | 19 (76) |
| No | 03 (12) | 06 (24) |
| (x) Waited at least 30 min at the immunization site for observation! | ||
| Yes | 02 (08) | 01 (04) |
| No | 23 (92) | 24 (96) |
* perception towards prior information given regarding time and place; #perception regarding the behaviour of immunization provider; @perception regarding the method of vaccination by immunization provider; $information whether four key messages were given or not after immunization; ! information regarding the observation period of 30 min post-vaccination
Only 20% (05) clients at high-performing centres said that they could not understand which vaccine was given to the child and the disease it protected against while 24% (06) clients at low-performing centres had a similar view. Around 68% (17) and 56% (14) of clients at low- and high-performing centres were not informed about scab formation after BCG vaccination while all clients (50) said that they were informed about the possibility of fever occurrence post-diphtheria, pertussis, tetanus (DPT) or pentavalent vaccine administration.
100% (25) of clients at low-performing centres were prescribed syrup or tablet paracetamol to be given after vaccination while 84% (21) clients at high-performing centres were given this prescription. The majority of clients at both high- (92%) and low-performing centres (96%) said that they never waited for at least 30 min post-vaccination at the vaccination site for observation.
Discussion
Along with improving vaccination coverage all over the country, it is imperative to focus on and uplift the qualitative aspect of immunization as well. Studies such as the present one can highlight the existing gap regarding immunization with respect to quality assessment. It can be evidently noted here that for routine immunization services to be successful, all its components such as planning of immunization sessions, cold chain and logistics management, reports, supervision, etc., should be carefully looked into. This requires continuous monitoring and evaluation.[9]
In the present study, out of total immunization sessions planned at all the top and bottom performing immunization centres, it was observed that 100% of the planned sessions were conducted. In a similar study conducted by Sanghavi et al. in Gujarat, it was found that at all the centres they visited, >80% of the scheduled vaccination sessions had been conducted.[9]
In the present study, when a comparison between high- and low-performing centres in terms of the last training was received, it was found that ASHAs at two centres in low-performing centres had never undergone any training for routine immunization. However, this difference was not statistically significant (P > 0.05). When assessed for logistics such as the provision of hub cutters and weighing machines, 100% and 80% of all the high-performing centres had functional hub cutters and functional weighing machines, respectively, and 80% of low-performing centres had functional hub cutters and weighing machines. In a similar study conducted by Kumar et al., it was found that the majority 42/45 of the participants working in the various immunization session sites were trained twice in the process of immunization and 71.43% of the total immunization sites under study had hub cutter installed at the sites.[10] In another study by Lodhiya et al. in Gujarat, it was found that 13% of healthcare workers (HCWs) underwent training regarding immunization in the past one year.[11] In another study by Barthakur et al., there was 100% availability of hub cutter with all the ANMs.[12]
In the present study, when a comparison between high and low-performing centres for cold chain and vaccine logistics management during immunization sessions at the session site was made, it was seen that if vaccines were not in use during immunization session, they were kept in the vaccine carriers at all of the 10 centres. Observation for vaccine availability at the session site revealed that at two (40%) of high- and low-performing centres, all vaccines were not available. The most common vaccine which was not available was the BCG vaccine. In a similar study by Sanghavi et al., it was found that 9/14 (64.29%) of the immunization sites had all the vaccines available.[9]
When activities that are part of standard protocol which have to be performed during immunization sessions (like checking Vaccine vial monitor (VVM), batch no and expiry date) were compared, it was found that ANMs at 60% of high performing and 80% of low performing centres followed this protocol. Out of a total of ten (11) centres, at nine (90%) of the centres, ANMs noted the time and date of opening on the reconstituted vaccine vials. When assessed for ‘safe injection practices’, with respect to no recapping policy for injection, four (80%) and two (40%) of high- and low-performing centres followed this policy and did not recap the injection after loading. It was observed that 80% of the ANMs updated their MCP card. At only one (20%) of low-performing centres, ANM was advising to stay for 30 min post-vaccination. In a similar study by Kumar et al., it was observed that 100% VVMs were found intact and 97% of HCWs noted the time of opening the vial.[10]
With respect to client satisfaction, 84% and 88% of clients at high and low-performing centres, respectively, said that immunization providers treated the beneficiary respectfully. The majority of clients at both high- (92%) and low-performing centres (96%) said that they never waited for at least 30 min post-vaccination at the immunization site for observation. In a similar study by Lo et al., only 1.2% of beneficiaries said that they waited for 30 min observation period and 98% received the four key messages.[13]
Our study demonstrates the necessity to address issues like information and education, vaccine adverse effects and vaccine accessibility to inspire HCWs, family physicians and the general community. These should all be brought up to provide quality immunization services to as many children as possible. A similar study based on coronavirus (COVID) vaccination highlighted this point and this can be applied to routine immunization as well.[14]
There were a few limitations in our study. One of the limitations was that the sample size for client assessment of quality services for immunization was not calculated and convenience sampling was used in place of that. Another limitation of our study was that not all 30 clusters were selected for evaluation and only 5 high-performing and 5 low-performing centres out of 30 clusters were selected considering the limited time availability.
Conclusion
The study highlights that most of the ANMs at the immunization centre were having good knowledge and were adequately trained for maintaining cold chains at session sites. Apart from this, the study also highlights that most of the immunization centres had proper logistics and immunization services. It was also revealed that there was a lack of refresher training for HCWs which if conducted from time to time would improve immunization services sufficiently.
Summary
ANMs working under routine immunization have good knowledge and are trained appropriately to maintain cold chains at the point of immunization sessions.
Supply of logistics at immunization centres was proper.
Refresher training should be organized at frequent time intervals to ensure HCWs remain updated with respect to immunization services.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
We thank all the parents/guardians and healthcare workers (ANMs and ASHAs) for giving us their valuable time and providing us with the necessary data and information.
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