Background
Methods
Study concept and objectives
Study setting and timing
Study subjects | Number | Details | Tools |
---|---|---|---|
Primary health care staff | 6 | Health Extension Officer or Specialised Nursing Officer | Semi-structured interviews (mix of quantitative and qualitative fields) |
6 | Nursing officers | ||
6 | Community Health Worker (CHW) | ||
Family members | 67 | Caregivers of infants being vaccinated, 66 female 1 male | Focus group discussion (10 groups) |
Health clinics and their operations | 9 | Child or family health clinic, static | Audit of infrastructure and equipment against PNG standards as described in national EPI plan [11]. Observation of general clinic procedures (12 sites) Observation using WHO Immunization Session Checklist (11 sessions) Observation of patient flow and staff-patient interactions (15 patients) |
3 | Mobile child health clinics (run by staff from the above sites) |
Data collection tools and ethical considerations
Analysis
Results
Strengths in local systems | Opportunities for improvement in local systems | |
---|---|---|
Local service planning and delivery Data sources: interview and audit | • Recent innovations recognised by most (14/18) staff: new vaccines or planning, with one mention of new quarterly outreach increasing efficiency • Recent in-service training in SIREP reported by many (11/18) staff • Static services available 5 days per week • All clinics tallied vaccinations to report into national health information system • 82% of clinics conducted as planned (annual total of 109 implemented of 133 planned) | • Outreach was limited - minority (2/9) static facilities used outreach with overnight stays for remote areas • Outreach planning process not able to be described by half the staff, less than a quarter planned on population basis, no clinics used population data to estimate outreach supply quantities • Many clinics with few patients: mean 17/clinic, IQR 3–26, maximum = 62 • Estimation of coverage impossible for more than half (10/18) staff due to lack of catchment data, only one clinic displayed coverage • No clinics with lists of children overdue for vaccination, one third of clinics used child registers • Local reasons for clinic cancellation were adverse weather, lack of transport or slow disbursement of funds |
Infrastructure and supplies Data sources: interview, audit and observation | • Most clinics had road access, with two outreach clinics on walking trails • Water supply in nine (of 12) clinics and electricity in eight (of 9) static sites • Functional injection equipment, safety boxes and weight scales in all clinics • 10 (of 12) clinics with appropriate, functioning cold chain equipment • Supplies of all relevant vaccines (including IPV and PCV) and injection equipment present • No expired or discontinued vaccines found | • Eight (of 12) clinic sites needed renovation (by local standards), 9 (of 12) did not have usable toilets • No clinics with kits for managing severe acute adverse events • Cold storage monitoring inconsistent, no clinics with written temperature records • Half the clinics had clear records of vaccine stock usage, not well reconciled with tallies of patients vaccinated, none able to match supply to population • Recording forms did not clearly account for three new vaccines: IPV, PCV, MR • Lack of important guidance documents: one (of 12) had an immunization manual, and four had child health standard treatment guidelines |
Staff knowledge and staff practice during immunization sessions Data sources: interview and observation | • More than half of staff could correctly cite recently introduced vaccines (11/18) and handling of lyophilised multi-dose vials (15/18) • Twenty staff (nurses and CHWs) across 12 clinics, vaccinating mean of 17 children per clinic falls below WHO maximums (30 per staff member [15]); • Core interactions (weight, screening and vaccination) done for 14 of 15 observed patients • Observation against WHO session checklist (Fig. 1) shows key elements of safe injection in over 80% sessions | • Less than half of staff could correctly cite immunization schedule (8/18), one national program target (3/18), storage temperature (6/18), interpret vaccine vial monitor display (3/18), or handling of liquid multi-dose vials (2/18) • Some important functions omitted in patient flow observations: educational interactions observed for just two of 15 patients, preventive care for mother and AEFI monitoring observed in none • Waiting times in 15 patient flow observations were significant: mean 51 min arrival to final interaction (IQR 13–90, maximum 210) • Observation against WHO session checklist sessions shows gaps in preparatory checking of vaccines, client communication and AEFI observation, and (for less than 20%) in safe injection |
Missed opportunities for vaccination Data sources: interview, audit and observation | • Most staff (13/18) stated they would open a multi-dose vial for just one patient | • Due vaccinations had been missed in 3 of 10 Child Health Record books • Reasons for missing vaccination included vaccine out of stock, clinic visit not for purpose of vaccination, or (for birth doses) childbirth in community • Two (of 15) observed patients asked to return another day for vaccination • Thirteen (of 17 respondents) staff stated they would usually ask a sick child to return at another time for vaccination |
Integration of other services Data source: interview and observation | • All staff noted a policy of integrating other care and vaccination • Nine (of 18) staff cited at least one other care (usually childhood illness) regularly integrated • Child illness care available in nine (of 12) clinics • Child illness care accompanied vaccination in seven (of 15) observed patients • Weight measured in all observed patients | • Four (of 18) staff mentioned maternal health service as integration option • Three clinics (of 12) lacked supplies, or service organization, to integrate childhood illness care with vaccination • No observation of catch-up vaccination with children presenting for illness • Three (of 15) patients observed to receive feeding counselling, two to receive vitamin A, 1 to receive albendazole • No observations of maternal preventive care or counselling • Staff reported insufficient numbers as main constraint on integrated care |
Community engagement and family viewpoints Data sources: interview, observation and focus group discussion | • Three (of 12) clinics provided verbal group health education alongside vaccination sessions • Three (of 18) staff reported support (for example food) provided by local communities • No fees for vaccines reported or observed and families did not report fees as barrier to vaccination | • No reported use of community-based trained lay health workers to help with organization, mobilization or education. • Six (of 12) clinics charged small administrative fees • Many families (6/10 groups) cited travel time, and transport costs, as significant constraints on timely attendance for vaccination • Many families (6/10 groups) sought more mobile clinics, more “on-demand” vaccination, and more reliable clinic timing • Some families (4/10 groups) sought more respectful staff-client interactions • No male family members were observed in attendance, staff cited embarrassment as a constraint on male involvement |
Local service planning, infrastructure, supplies and staffing
Staff knowledge and service delivery practices
Community engagement
Locally generated ideas for improvement
Discussion
Local actions already proposed in the PNG government’s SIREP strategy | Potential contribution of emergency responses or campaigns |
Local planning based on populations rather than geography | Campaign coordinators help boost local routine planning capacity Mapping child populations and data-sharing |
Intensified quarterly outreach focused on higher clinic numbers properly resourced and implemented | Identify new outreach points, especially with population clusters Clarify options and costs for transport |
System for tracking unvaccinated children | Mapping child populations and data-sharing |
Integrated SIAs with additional vaccines, matching local priorities | Involve district level in planning Local flexibility in an expanded package of campaign services |
Supportive supervision linked to refresher training including good communications and AEFIs | Distribute resources to staff Use campaign monitoring to collect staff priorities for capacity development |
Trained lay health workers (health volunteers) to track births and children, support outreach clinics and promote uptake at static clinics | Campaign organisation that promotes local involvement Leverage campaign supports to enlist long-term interest and support |
Local actions that go beyond the PNG government’s SIREP strategy | Potential contribution of emergency responses or campaigns |
Standardise every opportunity for vaccination, by policy, training and accessibility of vaccine supplies | Not easily addressed by emergency responses or campaigns |
Health communication products and programs to educate families on the complete vaccine schedule | Distribute family-oriented communications materials promoting catch-up vaccination |
Test models of integrated services, responsive to community preferences | Not easily addressed by emergency responses or campaigns |
Review of staff roles and functions to optimise allocations and workload | Minimise incentives that discourage outreach as part of routine programs |