factors affecting the implementation of immunization in jere local government area of borno state, nigeria

Description

ABSTRACT

The importance of immunization programmes cannot be overemphasized: it has contributed significantly to creating and sustaining good health In Nigeria, numerous approaches have been deployed but these interventions are not without challenges. We therefore aimed to explore factors affecting the implementation of immunization in Nigeria.

We used a qualitative approach and conducted the study in Jere Local Government Area of Borno State, Nigeria. We identified factors affecting the implementation of immunization through interviews with relevant stakeholders involved in vaccination communication in the health services. We also reviewed relevant documents. Data generated were transcribed verbatim and analysed using thematic analysis.

We used the SURE framework to organise the identified factors (barriers and facilitators) affecting vaccination communication delivery. We then grouped these into health systems and community level factors. Some of the commonly reported health system barriers amongst stakeholders interviewed included: funding constraints, human resource factors (health worker shortages, training deficiencies, poor attitude of health workers and vaccination teams), inadequate infrastructure and equipment and weak political will. Community level factors included the attitudes of community stakeholders and of parents and caregivers. We also identified factors that appeared to facilitate communication activities. These included political support, engagement of traditional and religious institutions and the use of organised communication committees.

Communication activities are a crucial element of immunization programmes. It is therefore important for policy makers and programme managers to understand the barriers and facilitators affecting the implementation of immunization so as to be able to implement communication interventions more effectively.

TABLE OF CONTENTS

COVER PAGE

TITLE PAGE

APPROVAL PAGE

DEDICATION

ACKNOWLEDGEMENT

ABSTRACT

CHAPTER ONE

INTRODUCTION

• BACKGROUND OF STUDY
• PROBLEM STATEMENT
• RESEARCH OBJECTIVES
• RESEARCH QUESTIONS
• SIGNIFICANCE OF THE STUDY
• ASSUMPTIONS OF THE STUDY
• LIMITATIONS OF THE STUDY
• DEFINITION OF TERMS

CHAPTER TWO

LITERATURE REVIEW

• REVIEW OF THE STUDY
• OVERVIEW OF IMMUNIZATION
• HISTORICAL BACKGROUND OF IMMUNIZATION
• VACCINATION OF CHILDREN
• IMMUNIZATION COVERAGE RELETED WORK
• IMMUNIZATION COVERAGE PER ANTIGEN IN NIGERIA 1995–2011
• CURRENT EPIDEMIOLOGICAL SITUATION OF POLIO IN NIGERIA
• FACTORS AFFECTING ROUTINE IMMUNIZATION IN NIGERIA

CHAPTER THREE

METHODOLOGY

• STUDY AREA
• STUDY DESIGN
• SAMPLING METHOD
• DATA COLLECTION METHODS
• DATA ANALYSIS

 

CHAPTER FOUR

• RESULTS AND DISCUSSION
• RESULTS
• DISCUSSION

CHAPTER FIVE

• CONCLUSION
• ABBREVIATIONS
• REFERENCES

 

 

 

 

 

CHAPTER ONE

• INTRODUCTION

1.1                            BACKGROUND TO THE STUDY

It is obvious that immunization is one of the most cost-effective public health interventions for reducing global child morbidity, mortality and life time disabilities (Chen et al, 2004). Worldwide, immunization prevents more than 2.5 million child deaths each year (WHO 2009). Global public health has greatly improved through the widespread use of vaccines, preventing millions of childhood hospitalizations and deaths each year rating immunization as a number one public health intervention (CDC, 2010 CDC 2009). Before the advent of immunization programs, infectious diseases such as measles, diphtheria, smallpox and pertussis were leading causes of child mortality (Stern et al., 2005). Tetanus toxoid vaccine is given to pregnant women to prevent against neonatal tetanus, which can be a major cause of infant deaths (KDHS 2014).

In the United States there has been a remarkable achievement in the control of vaccine preventable diseases resulting in decline in morbidity and mortality associated with vaccine preventable diseases (CDC 2010). In Africa, there has been tremendous improvement in the overall immunization coverage, though at a relatively slower rate (WHO 2004, WHO 2014). However, some African countries like Ghana, Morocco and Gambia have registered success in reaching coverage of over 90% (Ghana News Agency 2012, WHO 2014, UNICEF, 2014). The introduction of the immunization programme has led to continual reduction of vaccine preventable disease incidence.

Despite the remarkable achievements and improvements in immunization services, the agenda remains largely unfinished with large numbers of children (24 million) remaining unreached, unvaccinated or under-vaccinated (WHO, UNICEF & World Bank 2009). One-fifth of the world’s children which is about 22.4 million infants, are not immunized against VPD and 70 percent of these children come from 10 countries, Nigeria being one of them (WHO/UNICEF 2014), (UNICEF/WHO 2011), (UNICEF Australia 2013). One of the causes of high mortality rates in Nigeria are vaccine-preventable diseases. Previous studies have explored factors associated with implementation of childhood immunization programs, however most of these studies focused on the demand side factors. Some of the most cited demand-side factors that have been shown to influence functioning of immunization programs include parity, household income, ethnicity, place of delivery, mother’s level of education, distance to health facility, culture, religion, age and forgetfulness of guardian due to preoccupation with other activities, et al., 2014)(Kariuki, 2004) Mutua et al., 2011). There are relatively few studies examining supply-side factors influencing implementation of childhood immunization programs in the Nigerian context, particularly in predominantly rural areas. This study aims to fill this gap. The relatively poor health indices and large size of the county makes it a reasonable choice for understanding the factors influencing implementation of immunization programs in primary healthcare facilities in Nigeria.

1.2                                 STATEMENT OF THE PROBLEM

Immunization program is a key strategy for prevention of child and neonatal deaths and lifetime disabilities. Immunization prevents 2.5 million child deaths each year (WHO, 2009). Despite the global improvement in vaccine coverage that has seen 84% of children around the world receiving this life-saving intervention, 10 million children in low and middle level countries die before reaching age of five (Arevshatia et al, 2007) (WHO 2014). Full immunization potential has not yet been realized in many countries where 22.4 million Children around the globe are not fully immunized. Majority of not fully immunized children 70% are from 10 countries, Nigeria being one of them (WHO/UNICEF 2014). Low immunization coverage remains a challenge even in a committed country like Nigeria. This study sought to identify intervention targets for improving immunization coverage by investigating factors affecting the implementation of immunization in Jere Local Government Area of Borno State, Nigeria. The focus was to identify factors contributing to missed immunization and ways to reduce the number of missed opportunities for immunization at the health facilities. Much effort has been made to provide vaccines through the GAVI alliance, enabling states to acquire the recommended vaccines. In Nigeria for instance, vaccines are made freely available to the public, yet over 20 percent of Nigerian children are not immunized each year. There is a need to identify strategies for improving implementation of vaccination programs in the country, particularly at primary health care level in predominantly rural areas and this study aimed to fill this gap.

1.3                                 RESEARCH OBJECTIVES

The general objective or main objective of this study is to examine the factors affecting the implementation of immunization in Jere Local Government Area of Borno State, Nigeria. The specific objectives are:

1. i)             To understand the factors affecting the implementation of immunization in Jere Local Government Area of Borno State.
2. ii)           To identify the problem of immunization in Jere Local Government Area of Borno State.

iii)         To understand the attitudes of parents toward immunizing their children in Jere Local Government Area of Borno State.

1.4                                 RESEARCH QUESTIONS

The following are some of the questions which this study intends to answer:

1. i)             What are the factors affecting the implementation of immunization in Jere Local Government Area of Borno State?
2. ii)           What are the problems of immunization in Jere Local Government Area of Borno State?

iii)         What are the attitudes of parents toward immunizing their children in Jere Local Government Area of Borno State?

1.5                                 SIGNIFICANCE OF THE STUDY

The findings of this study are of great significance to immunization program managers and policy makers in geographical areas with large rural populations. It provides a basis for rational interventions to improve vaccine delivery in primary healthcare facilities, improve vaccination coverage indices and reduce the burden of childhood infectious diseases. The results are of benefit to the county health management team by providing actionable information relevant for planning and policy making to improve delivery of childhood vaccines in the county. This study contributes to the broader literature addressing how to improve implementation of childhood immunization programs in rural areas by providing an empirical analysis of challenges faced by program implementers. Specifically, this study seeks to contribute to the literature related to the identification of intervention targets for increasing the effectiveness of immunization programs in primary healthcare facilities in Jere Local Government Area of Borno State, Nigeria.

1.6                                 ASSUMPTIONS OF THE STUDY

This study investigates the factors affecting the implementation of immunization in Jere Local Government Area of Borno State, Nigeria. It will therefore be carried out in the four regions (north, south, east and west) of the local government area.

1.7                             LIMITATIONS OF THE STUDY

Health care institutions always have very busy schedules and work in shifts. This was seen as one of the limitations of identifying appropriate time periods to administer surveys. This was addressed by obtaining phone contacts of health facility managers and scheduling interview dates ahead of time. The study might have also been affected by the way respondents would answer questions in the data collection tool, they could have chosen answers that are socially desirable to be seen as performing well.

1.8                                 DEFINITION OF TERMS

The following terms were used in the course of this study:

Immunization: is the process by which an individual’s immune system is stimulated through exposure to an immunogenic agent known as vaccine (a substance that stimulates the immune system is said to be immunogenic)

Implementation: Is a specified set of activities designed to put a plan or strategy into practice. In this study, it refers to the set of activities put together in the immunization program to ensure that children are vaccinated and thereby increase immunization coverage.

Immunization programs: is a set of activities designed to ensure all eligible children and women. In a specific location receive timely vaccination and become immunized against specific vaccine-preventable diseases. The programs include childhood immunization and maternal immunization

1.9                                                  REVIEW OF THE STUDY

Immunization is aimed at the prevention of infectious diseases. In Nigeria, the National Programme on Immunization (NPI) suffers recurrent setbacks due to many factors including ethnicity and religious beliefs. Nigeria is made up of 36 states with its federal capital in Abuja. The country is divided into six geo-political zones; north central, north west, north east, south east, south west and south south.

At the end of 2011, Nigeria was estimated to have a population of 167 million [NPC, 2009]. The Expanded Programme on Immunization (EPI), introduced in 1978 with the aim of providing routine immunization to children less than the age of two years, recorded initial but intermittent successes. The optimum level was recorded by the early 1990s with the country achieving a universal childhood immunization coverage of 81.5%. But since that period of success, Nigeria has witnessed gradual but consistent reduction in immunization coverage. By 1996, the national data showed less than 30% coverage for all antigens, and this decreased to 12.9% 2003 [2]. This figure which is consistent with the 2003 national immunization coverage survey figures is among the lowest in the world and explains the poor health status of children in the country. It is the worst in the west African subregion, only better than Sierra Leone. For instance, the polio epidemic in Nigeria is the worst in the African region and constitutes threat to other nations [Obioha, 2010].

The vision of EPI in Nigeria is to improve the health of Nigerian children by eradicating all the six killer diseases, which are polio, measles, diphtheria, whooping cough, tuberculosis, and yellow fever. Between 1985 and 1990, as outlined in the national health plan for that period, the objectives of EPI were to strengthen immunization, accelerate disease control and introduce new vaccines, relevant technologies and tools. In1995 in line with the above, Nigeria became a signatory to the World Health Assembly, adopted the World Health Assembly Resolution (WHAR) and United Nations General Assembly Special Session (UNGASS) goals for all countries to achieve by 2005 (i) polio eradication, (ii) measles mortality reduction and (iii) maternal and neonatal tetanus elimination (MNTE). Nigeria also adopted the millennium development goals (MDGs) calling for a two-third reduction in child mortality, as compared to 1990, the year 2005. In addition to the above, the country ratified the United Nations General Assembly Special Session (UNGASS) goals urging Nigeria to achieve by 2010 (i) ensure full immunization of children under one year of age at 90% coverage nationally with at least 80% coverage in every district or equivalent administrative unit, and (ii) vitamin A deficiency elimination. In 1998 following from the above, Nigeria laid out the core activities of EPI policies which included the following: (i) monitoring of the performance, quality and safety of the immunization system through indicators; (ii) assessment of the current burden of vaccine-preventable diseases as well as the “future” burden of vaccine preventable diseases in terms of sickness, death and disability, as well as the economic burden; (iii) assessment of the impact of vaccination strategies, through on-going epidemiological surveillance and reliable laboratory confirmation, as well as impact assessments in Nigeria; (iv) monitoring of the national immunization policies, particularly the vaccines used in the country and the target population for these vaccines (immunization schedules); and (v) monitoring of the overall proportion of children and women who are vaccinated (immunization coverage) and ensuring that all districts of the country are well covered with vaccination. In 2000, following the African Regional Summit on EPI held in Harare in November 1999, the Federal Ministry of Health specifically stated its policies on the country’s initial visions for EPI as follows:
(i) Immunization System Strengthening: By the year 2004, Nigeria should achieve the EPI district-focused plan and attain 80% DPT3 coverage in all the states of the federation. The specific policy also stated that the government should ensure increased funding for EPI.
(ii) Accelerated Disease Control: By the year 2004, there should be no cases of acute flaccid paralysis associated with wild poliovirus in Nigeria. As for measles, by the year 2004 the country should have reduced measles morbidity by 90% and measles mortality by 95%; while the coverage for yellow fever is expected to increase to at least 80%.

(iii) Innovations: By the year 2004, Nigeria should include vitamin A and hepatitis B (HB) in its national immunization programmes; and the vaccination coverage should not be less than 80% as with other antigens. Under the new technology drive, the country should adopt the multi-dose vial policy (MDVP) and vaccine vial monitor (VVM) and also introduce new methods for monitoring its use [4].

Immunization against childhood diseases such as diphtheria, pertussis, tetanus, polio and measles is one of the most important means of preventing childhood morbidity and mortality. Achieving and maintaining high levels of immunization coverage must therefore be a priority for all health systems. In order to monitor progress in achieving this objective, immunization coverage data can serve as an indicator of a health system’s capacity to deliver essential services to the most vulnerable segment of a population [5].

CHAPTER FIVE

5.1     Conclusion and recommendation

Our earlier work has shown that a wide range of communication interventions are being used to promote uptake of childhood vaccination in Nigeria [Oku et al, 2016]. However, a number of health system factors such as funding constraints, inadequate infrastructure and equipment, health worker-related and political factors as well as community level factors, such as the attitudes of community stakeholders and members, were found to hinder the delivery of vaccination communication interventions. Important differences were observed across and within the two states studied. Most of the barriers to implementing vaccination communication strategies found in this study were strongly expressed in Jere, and also in rural compared to urban areas. These differences can be attributed to differences in infrastructure, resources (human and financial) and accountability as a consequence of investments in the polio eradication programme in Jere.

Programme managers and front line providers reported that the most consistent barrier to delivering vaccination communication was inadequate funding. This, they suggested, has greatly impacted on vaccination communication delivery and the disbursement of communication materials, especially to areas where they are most needed. In resource constrained settings like those studied, systems should be put in place to improve efficiency in how available resources are utilized. For instance, gains could be made by integrating routine EPI messaging into vaccination campaigns or packaging this with communication around other well-funded childhood interventions. Another important barrier was the absence of strong political will at Local government levels for implementing immunization.

Decision makers need to look at how to address these barriers so as to facilitate the implementation at scale of evidence-informed strategies for communicating with parents and caregivers regarding childhood immunization. Addressing communication gaps, especially in immunization services, will require bridging the current funding gap, addressing human resource deficits and ensuring strong political will for implementation. Facilitators for implementation of vaccination communication interventions, such as the engagement of traditional and religious institutions and the use of organised communication committees, should be strengthened. If sufficiently planned, funded, and integrated with service delivery, vaccination communication activities could meet their desired objectives.

Abbreviations

COMMVAC 2:    ‘Communicate to Vaccinate’ Project 2

DPT3:                    Combined diptheria, pertusis and tetanus vaccine, three doses

EPI:                        Expanded programme on immunization

FCT:                       Federal Capital Territory

GAVI:                    The Vaccine Alliance

LGA:                      Local Government Area

LMIC:                    Low and middle income countries

NPHCDA:             National Primary Health Care Development Agency

WHO:                    World Health Organization