Vaccination sessions; challenges and opportunities for improvement: Experiences from Karnataka

Background: It is estimated that immunization averts between 2 and 3 million deaths every year. India has declared 2012-2013 as a year of intensification of routine immunization. Because the doctors train the health workers and paramedics in proper implementation of vaccine delivery, their knowledge should be perfect and no error or ambiguity of any sort is pardonable. Research Question: What is the operational knowledge about immunization among doctors? What is the effect of training in routine immunization among doctors? What is the effect of supportive supervision on field staff? Setting: Directorate of Health Services, Bangalore on 06/03/2007, East Godavari on 11/03/2007, Bangalore Mahanagar Pallike on 5-7/10/2007 and Mandya on 8-10/03/11. Supervision sessions were conducted at 33 sites of the Dakshina Kannada district. Study Design: This study is cross-sectional. Participants: Participants include RCH officers, medical officers, and immunization field staff. Materials and Methods: The questionnaire and interview method was followed. The pretest questionnaire was administered to RCH officers and MOs. The training program in two of these four areas was held immediately and the impact of training through the posttest was studied in one area. Supportive supervision sessions were then conducted in purposively selected immunization sites. Results: The overall knowledge among doctors improved after the training session. The mean score improved significantly in all the variables included in the study. Supportive supervision was also found useful in improving the routine immunization sessions at the field level.

Keywords: Doctors, field, immunization, knowledge, supervision, supportive

Vaccination through routine immunization (RI) is known as the utmost cost-effective service, which is a right of every child. Vaccination coverage is a traditional measure of the success of immunization programme. Globally, an estimated 24 million children remained unreached by the immunization programme in 2008; about three quarters of these unimmunized children live in 10 developing and underdeveloped countries: Chad, China, Congo, Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan, and Uganda. ^[1],[2] India has 10 million unimmunized children which is the highest in the world, ^[3] while the main focus is on increasing and substantiating vaccination coverage, this may mask the underlying delays of vaccination. Significant such fallacies may occur even with a massive coverage. Palpable success of immunization in eradicating small-pox scourge resulted in recognition of immense potential of immunization as a public health intervention. Routine immunization gradually figured in the priority list of national public health programmes and WHO introduced the EPI. Then, the UIP was placed in 1985 to cover all the districts in the country by 1990. UNICEF – Coverage Evaluation Survey India 2009, revealed 61% of children were fully vaccinated nationally, whereas >78% were fully vaccinated in Karnataka. However, mere vaccination would not ensure immunization if the vaccine administered has lost its potency during the course of its storage, handling, and wrong practices in vaccine administration.

Proper handling, storage, and administration of vaccines to the beneficiaries are very critical. A good operational knowledge is essential for all health care providers, doctors, nurses, and paramedics, which can alleviate programmatic errors and minimize the gap between vaccinated vs. immunized. An effective, regular, universal monitoring of the sessions using the standard data collection tool, compilation, quick analysis to generate necessary information for appropriate action is very much essential, more so in the view of on-going polio eradication and vaccine preventable diseases (VPDs) control programme. ^[4]

Aim

The aims of this study are:

1. To assess the operational knowledge regarding routine immunization among the RCH officers, medical officers.
2. To assess the outcome of supportive supervision sessions in select immunization sites.

The study was done at Directorate of Health and Family Welfare services Bangalore for 25 RCH Officers on 6/3/2007, East Godaveri region 50 Medical Officers on 11/3/2007, 100 MOs of BMP on 5-7/10/2007, and 20 MOs of Mandya on 8-10/3/2011. Knowledge was assessed with the help of a semi-structured pretest questionnaire. We assessed the knowledge about operational aspects of RI and other aspects such as economic aspects were not studied. Totally there were 195 doctors. Among the BMP group, 85% of study subjects possessed MBBS degree, and 15% had DCH (Diploma in Child Health) and DGO (Diploma in Obstetrics and Gynecology) after MBBS.

We then conducted supportive supervision of immunization sessions at the field practice area of K.V.G. Medical College, Sullia, with the help of a Government of India tool ^[3] from April to June 2011. The team included MBBS interns intensively trained for 4 days by the authors. Every third session was monitored (out of 91 sessions, 33 sessions were supervised in a month). We used systematic random sampling of sessions. Data were collected using the standard tool designed by Government of India, both for session monitoring and house to house survey. The tool was expanded to include additional indicators. The training included routine immunization and monitoring as per the standard operating procedures (SOP). The questions were asked on the National immunization schedule, cold chain management, logistics, safe injection and waste disposal, AEFI, community involvement and communication, supportive supervision, records reports, and data for action. Ethical clearance for the supportive supervision was obtained from the Ethical Committee of the Institution. The data entered on the Microsoft excel spread sheet and analyzed with excel and StatCalc software.

A 2-day intensive structured training programme given on RI for 100 medical officers of BMP in three batches in October 2007. The test score was compared of pre and post. Definitions used in the current study and the calculations are taken from the Immunization Handbook for Medical Officers. ^[3]

The questions were pertaining to the following components:

1. UIP programme component
2. Vaccine administration
3. Cold chain and logistics
4. Injection safety and waste management
5. Adverse events following immunization

Observation

The results of the study are as follows. The knowledge level of the doctor’s pretest was lower as compared to that of the posttest. Overall knowledge about RI was only 62.5%. Moreover, 96% of the RCH officers revealed that they need adequate training in this field.

When a paired t-test was applied to [Table 1], the difference in knowledge was found to be statistically significant. The mean score improved significantly in all the variables, thus stating that training was useful. The similar substantial gap in knowledge was detected among the medical officers of EGA on 11/03/2007. The mean score of the pretest was 30.65% and the posttest was 48.68%. The same operational gap was also detected among the participants of the MAN district. All of the medical officers found a need for training and thought that training had definitely improved their knowledge about RI.

The follow-up of training effectiveness after 6 months and 1 year could not be done due to some bottlenecks which cannot be published. Conditioning of the ice pack is thought to have been done if the sound of water is heard on shaking it. Its surface is covered with beads of water. Used AD syringes were cut at the hub immediately using a hub-cutter, needles collected in the hub-cutter were brought to PHC, disinfected and then put in the disposal pit. Body with plunger of the cut AD syringe were also disinfected and disposed for recycling. Disposal of swabs is done by burning or incineration. It should be done by segregation at source by Class 4 and ANMs together. For simplifying the issue, only BMP data are shown in [Table 2].

[Table 2] states that the knowledge about the conditioning of the icepacks and disposal of biomedical waste (AD syringes and swabs) is primarily lacking in the doctors. The doctors act as trainers to the junior staff working under them. Vaccination sessions are regularly held on all Thursdays at the facilities and outreach sessions are held once in a month on a fixed day at Health subcentres/Anganwadi centres in the field as per National/ state guidelines. PHCs are the ILR points where vaccines are stored.

[Table 3] shows the various aspects in which supportive supervision of session sites was conducted in the study.

Borker et al. did a study on IDSP training at the Kannur district of Kerala and found that training was effective, there was a need to organize more number of training programmes and need for appropriate retraining for doctors of the Kannur district of Kerala. Thus, we concluded that if doctors are given adequate training then they will act as good resource persons to train their health functionaries working under them. The same results for knowledge aspects were found in the current study. ^[5]

In a camp at Hooghly district’s Goghat area, West Bengal, India, instead of polio vaccine hepatitis B vaccine was administered orally to children that left 67 children ill. Four health workers, including the camp supervisor and an Anganwadi worker, had been identified by a parent accidentally. ^[6] Such a type of mishaps which can be misinterpreted by public easily but which might not even have significant repercussions medically can be avoided in the near future if proper knowledge and supportive supervision facilities are made available in priority by the health sector functionaries at all time. Doctors and RCH officers of each district need to train the vaccinators appropriately and in a timely fashion. The training should be so genuine that their behavior change should occur. In such a case which could scare the community at large the onus lies with the doctors and the medical fraternity to educate the community and protect them from scare. In the current study while doing supportive supervision, we found that the health staff coordinated well and the atmosphere was conducive for learning.

Babu did a study on supportive supervision in the Bellary district of Karnataka as this district had 18 confirmed polio cases in year 2003. They defined it as process that promotes quality at all levels of the health system by strengthening relationships within the system, focusing on the identification and resolution of problems, and helping to optimize the allocation of resources promoting high standards, teamwork, and better two-way communication. They clearly described a job, mentored, and assessed work performance, trained and handheld support. They found that at no instance a fault finding mechanism could be effective in the study setting and supportive supervision appears to be sustainable. They have revealed the reasons for not practicing this programme by the country as a whole. The external agencies are not being involved freely, adequate manpower may be lacking in the agency, and legally it might not be right for the external agency to comment on financial and other disciplinary aspects of the programme. In Bellary district, they found that the ANM positions were vacant, roads were inaccessible, and urban areas were outside the ambit of health services. ^[7] Efforts led by the Govt. of Karnataka with collaboration from the WHO and UNICEF who played key roles interrupted polio transmission in the Bellary district in 2003. Further, a state core group on routine immunization was formed to sustain the gains made in polio immunization and to improve immunization coverage against other VPDs. In this study, we did not involve an external agency but we did internal supportive supervision of the health workers. Such problems of vacant staff are not found in the Dakshina Kannada district of Karnataka, educational status is relatively good, and that was the reason why we could do it in the current setting even with financial and material constraints.

Khowaja et al. did a study among Pashtun community in Pakistan among 1,017 parents to assess their knowledge and perceptions regarding polio and its vaccine and found reasons for nonparticipation in the immunization programme. The main reasons cited by them were fear of sterility, lack of faith in polio vaccine; scepticism about vaccination programme and the fear that vaccine might contain religiously forbidden ingredients. ^[8] In the current study, four key messages are given to the mother by 93% of workers. If the doctors have adequate knowledge, they will be able to influence the health workers who can in turn influence the local community to actively participate in the immunization programme. The integrated community participation needs adequate and effective communication which thence can stand as a pillar in prevention of VPDs.

In a study by Muhammad et al., in a rural district of Punjab province of Pakistan, the qualitative technique of the focus group discussion and in-depth interview in Polio programme was used where they found that immunization managers faced lot of hurdles in procuring the vaccines, maintaining cold chain facilities, and also conducting immunization sessions. The managers came up with eye-opening fearless remarks on the system of services used in the province. The authors thus recommended that more studies of this nature may be carried out, although it may involve biases. They went on further to say that studies on supportive supervision should also be carried out in the subcontinent. ^[9] Since India is sailing in the same boat in terms of immunization service delivery at least in certain districts of the country, the current study would be of use to resource poor countries at large.

Nandan et al. did a multicenter study in the seven states in India, by joint collaboration from the WHO and NIHFW. The medical officers of the PHC said that they monitor four session sites in a month and other supervisors monitored seven session sites in a month during the last 3 months, and no records were found in 45% of the PHCs. Fifty-six percentage of health workers reported that the medical officers had visited their session sites in the last 3 months while 63% reported the visit of other supervisors. ^[10] The current study we did not only learn to conduct a proper supportive supervision session, but also learnt how to do capacity building of ANMs, AWW and the ASHA workers, the main auxiliaries working continuously in the field. Due to financial and material constraints, only 60% session sites were monitored regularly by our supervisory team.

Wadgave et al. did a study in the Solapur district of Maharastra on 420 under five selected from six slums. They found that mother education, socioeconomic status of the family, lack of mothers knowledge about vaccination, and fear of losing daily wages were responsible for the children remaining unvaccinated. ^[11] If the health workers educated the mothers appropriately this problem could be solved. The authors agree that it would be very easy to theoretically accept that it might get solved but the hard fact remains that there are so many difficulties in the field settings.

Yadav did a study at Ballabgarh Delhi to estimate the vaccination delays and explored the causes of these delays. They found that significant vaccination delays can occur even with high vaccination coverage areas. Nonavailability of the child at home followed by giving less priority to the schedule was thought to be important reasons for the delay. ^[12] The situation in the Dakshina Kannada district is also similar with high vaccination coverage, but with delays. Moreover, this suggests that supportive supervision, effective communication, and capacity building should ideally go hand in hand.

Since the launch of mother and child tracking service (MCTS) ^[13] in Karnataka the problems faced by other authors of unacceptability of services have come down to certain extent more so in the Dakshina Kannda district of Karnataka. The current study thus states that integration of the supportive supervision with the MCTS can go a long way in making marvels in the field of RI.

Limitations

1. Some of the questions may have been wrongly understood as the questionnaire was not administered to the doctors (RCH officers and MO).Q1. The site of injection is swabbed with by whom before injecting.Ans. Wet sterile swab by service provider.

   Q2. After withdrawing needle the injection site is covered with by whom .

   Ans. Dry sterile swab by beneficiary.

2. Follow up of training should have been done after a fixed duration of 6 months to 1 year.
3. We did not try to do a qualitative study (the Focus group discussion) in the supportive supervision group due to feasibility reasons in the field settings.

The current study thus states that integration of the supportive supervision with the MCTS can go a long way in making marvels in the field of RI. Supervising supportively can make the immunization sessions effective in terms of better participation and services. Hence adequate and effective training of program managers and medical officers is strongly recommended. More studies of such nature are of immense use in the field of public health.

We all authors acknowledge the help of Taluk Health Officer, Medical Officers and other study participants, auxillary Field staff of Sullia Taluk of Dakshina Kannada district.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.133716

[Table 1], [Table 2], [Table 3]