UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES ASSESSMENT OF SECOND YEAR OF LIFE IMMUNIZATION PERFORMANCE IN THE ACCRA METROPOLIS BY OXYGEN GERSHION WULLAR (10359747) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL APPLIED EPIDEMIOLOGY AND DISEASE CONTROL DEGREE JULY, 2019 DECLARATION I Oxygen Gershion Wullar hereby declare that except for the peoples' work that have been duly acknowledged, this proposal is the result of my own work, done under supervision and it does not contain any materials which has been accepted for award of any degree at a university . Oxygen Gershion Wullar (Resident) Date: .. a.JJ~J.~.q .................. .. • ~2 _> Dr. Adolphina Addoley Addo-Lartey (Academic Supervisor) . 0 M_ 1- ;5 l 1-v 1--c:; Date ................................................ . Dr. Priscilla Nortey (Academic Co-supervisor) ' tJ "3 - 10-'Ql)I c;-Date: .................................................. . DEDICATION This work is dedicated to the Oxygen family, my mother Mrs Juliana Dei who is late, my father Mr. Francis Dei and all my beloved ones. ii ACKNOWLEDGEMENTS I wish to thank Almighty God, the higher, gracious and the most merciful father, all praises to him for the strength and His blessing in completing this work. My gratitude goes to my beloved wife, Mrs Anita Wullar and my children Bless, Eunice, Oxyboy, Oxyqueen and Oxyjunior for their endless love, prayers and encouragement. Special appreciation goes to my supervisor, Dr. Adolphina Addoley Addo-Lartey, for her supervision and constant support. Her invaluable help of constructive comments and suggestions throughout this work have contributed to the success of this research. I would like to express my gratitude and sincere thanks to Dr. Stella Gyamfi whose contribution to stimulating suggestions and encouragement, helped me to coordinate my work especially in writing this research report. I would like to express my appreciation and sincere thanks to all staff of Okaikoi Sub Metro Health Directorate Especially Disease Control Officers, Public Health Nurses and Community Health Nurses at Kaneshie Polyclinic and Achimota. The last but not the least Special thanks go all mothers participated in focus group discussion for their input. iii ABSTRACT Background Vaccination in the second year of life is to boost the immunity of children after the first birthday to five years of age. The second-year vaccination exposes children who did not seroconvert during the first year of life vaccination in nine months to now have the opportunity to be fully immunized against killer diseases. The study assesses suboptimal second year of life immunization coverage performance in Okaikoi Sub metro, Accra Metro for 2017. Method A mixed method comprising of a qualitative and a quantitative study was used to assess health workers, health facilities and guardians of vaccinees. Semi-structured questionnaire was used for 169 respondents in 28 outreach sites visited and 2 focus group discussion conducted. Chi-square tests were used for bivariate associations between categorical variables and Fisher's exact tests used in instances where the assumptions underlying Chi-square failed (i.e. low expected cell frequencies). Wilcoxon rank-sum test was also used to investigate if significant differences in output levels existed between facilities that had a shortage of vaccines and those that did not. Results The results showed that facilities without shortage had a mean output level of 23.3% compared to the mean output level of 49.8% for those with shortage and this difference was highly significant (p<0.001 ). All facilities that know of the second year of life catch up policies also had a shortage of the vaccines compared to only some of those that did not know the policies and these differences were significant (p<0.007). Most mothers do not go for vaccination after 9 months due to health staff not scheduling them as identified in focus group discussion. iv Conclusion Shortcomings identified in this research shows that serious challenges do exist which have to be addressed when vaccines are introduced. The irregular vaccine shortage in the facilities and staff not scheduling for 18 months after receiving 9 months vaccination is found to be some factors affected the vaccination coverage performance which if addressed will significantly help improve the second year of life immunization coverages. Key words: Measles-Rubella, Meningococcal A Conjugate, immunization, vaccination, coverages. V Table of Contents DECLARATION ............................................................................................................................ i ABSTRACT .................................................................................................................................. iv LIST OF FIGURES ..................................................................................................................... ix LIST OF TABLES ....................................................................................................................... xi ABBREVIATIONS .................................................................................................................... xiv CHAPTER ONE ............................................................................................................................ 1 INTRODUCTION .......................................................................................................................... 1 1.1 Background ............... .......... ....................................... ............ ................. .......... ........................ 1 1.2 Problem Statement ............................................................ .............. .......................................... 4 1.3 Justification .............................................................................................................................. 5 1.4 Conceptual framework ....................... .... ......................................................... .......................... 7 1.5 General objective ....... : .............................................................................................................. 8 1.6 Specific objectives .......................................................... .......................................................... 8 CHAPTER TWO ..................................................................... ...................................................... 9 LITERATURE REVIEW ............................................................. ................................................ 9 2.1 Vaccination providers in Ghana .......................................................................................... ...... 9 2.2 Benefit of vaccination ............................................................................................................... 9 2.3 CHPS concept and imm unization ........................................................................................... 10 2.4 District immunization focus ............ ............................................................ ............. ....... ........ 11 2.5 Immunization programme in Ghana .............................................. ......................................... 12 CHAPTER THREE .................................................................................. ................................... 15 METHODS ................................................................................................................................... 15 3.1 Study Area .............................................................................................................................. 15 3.2 Study Population .................................................................................................................. ... 17 3.3 Study type and design ................................................................................................ ............. 17 3.5 Sample size ........................... ................................................................................................. . 20 3.6 Sampling method .................................................................................................................... 20 3.7 Data collection .......................................... ................................................... ........................... 21 3.8 Data analysis and processing .................................................................................................. 21 3.9 Ethical consideration ........................................................................................................ ....... 22 CHAPTER FOUR ........................................................................................................................ 23 RESULTS ..................................................................................................................................... 23 4.1 Coverages .......................................... ...................................................................................... 23 vi 4.2 Service Providers Factors ....................................................................................................... 49 4.3 Health facility factors .............................................................................................................. 57 4.4 Community Factors ....................................................................................... .. ........................ 72 4.4.1 Community Mobilization Arrangements ............................................................................. 72 · 4.5 Information on Mothers Who Took Part in Immunization ..................................................... 72 4.5.1 Kaneshie zone ...................................................................................................................... 72 4.5.2 Achimota zone .................................................... ................................................................. 73 4.6 Mothers' Perception of Imrr.unization .................................................................................... 74 4.6.1 Kaneshie ...................................................................................................... .. ........... 74 4.6.2 Achimota .............................................................................................................................. 75 4.7.1 Kaneshie ............................................................................................................................... 75 4.7.2 Achimota .............................................................................................................................. 76 CHAPTER FIVE ................................................. ........................................................................ 77 DISCUSSION ......................................................................... ...................................................... 77 CHAPTER SIX ............................................................................................................................ 83 CONCLUSION AND RECOMMENDATIONS ....................................................................... 83 6.1 CONCLUSION ....................................................................................................................... 83 6.2 RECOMMENDATION .......................................................................................................... 84 REFERENCES ............... .............................................................................................................. 85 APPENDIX I ......................................... ....................................................................................... 87 1.1 Participants information sheet ................................................................................................ 87 1.1.1 Introduction ............. .. ...................................................................................................... ..... 87 1.1.2 Background and Purpose of the Research .......................................................................... 87 1.1.3 Nature of Research ............................................................................................................... 87 1.1.4 Duration / what is involved .................................................................................................. 88 1.1.5 Potential Risks ..................................................................................................................... 88 1.1.6 Benefits ................................................................................................................................ 88 1.1.7 Costs ..................................................................................................................................... 88 1.1.8 Compensation ...................................................................................................................... 88 1.1.9 Confidentiality .................................................................................................................... 88 1.1.10 Voluntary Participation and withdrawal ............................................................................ 88 1.1.11 Outcome and feedback ................................. ...................................................................... 88 1.1.12 Feedback to Participants .................................................................................................... 88 vii 1.1.13 Funding information .......................................................................................................... 89 1.1.14 Sharing of Participant Information / Data .......................................................................... 89 l .1.15Data storage and usage ........................................................................................................ 89 1.1.16 Conflict of interest ............................................................................................................. 89 1.1.17 Contact .......................................................................................................................... ..... 89 1.2 CONSENT FORM .................................................................................................................. 90 1.2.1 PARTICIPANTS' STATEMENT ....................................................................................... 90 1.2.2 INTERPRETERS' STATEMENT ....................................................................................... 90 1.2.3 STATEMENT OF WITNESS ............................................................................................. 91 1.2.4 INVESTIGATOR STATEMENT AND SIGANTURE ...................................................... 91 1.3 Data Collection Instruments ................................................................................................... 92 1.3 .1 Heads of Institutions ............................................................................................................ 92 1.3.2 Public Health Nursing Officers ............................................................................................ 93 1.3.3 Community Health Nurses ................................................................................................... 94 1.3.4 Focus Group Discussion Guide .............................................. ............................................. 95 1.3.5 Focus Group Discussion ...................................................................................................... 96 1.3.6 Interviewer questionnaire /Observation Checklist.. ............................................................. 97 1.3.7 Checklist For Cold Chain Equipment.. ................................................................................ 98 1.3.8 Checklist For Vaccines, Needles,Syringes,Child Health Records And Tally Registers ..... 99 1.3.9 Questionnaire for Opinion Leaders (Assembly Members/Unit committee members) ...... JOO APPENDIX II ............................................................................................................................. 101 ETHICAL CLEARANCE ......................................................................................................... 101 viii LIST OF FIGURES Figure 1: Conceptual Framework for Improved Second Year of Life (2YL) Immunization in Accra Metropolis ............................................................................................................................ 8 Figure 2: Shows the map of study area Okaikoi Sub Metro within Greater Accra and Accra Metropolis ..................................................................................................................................... 15 Figure 3: Okaikoi Submetro mmual percentage performance for some indicators for 2017 and 2018 .................... ................................. ..................... ..................................................................... 27 Figure 4: Okaikoi Submetro annual percentage performance for some indicators for first the quarter of 2017 to 2019 ..... : ........................................................................................................... 28 Figure 5: Monthly availability of Conjugate A Meningococcal vaccines in Okaikoi Sub metro for 2017 ......................................................................................................................................... 57 Figure 6: Monthly availability of Conjugate A Meningococcal vaccines in Okaikoi Sub metro for 2018 ............................... ... ....................................................................................................... 58 Figure 7: Monthly availability of Conjugate A Meningococcal vaccines in Okaikoi Sub metro for the first four months in 2019 ................................................................................................... 59 Figure 8: Monthly availability of Measles-Rubella vaccines in Okaikoi Sub metro for 2017 .... 60 Figure 9: Monthly availability of Measles-Rubella vaccines in Okaikoi Sub metro for 2018 .... 61 Figure 10: Monthly availability of Measles-Rubella vaccines in Okaikoi Sub metro for first four months in 2019 .............................................................................................................................. 62 Figure 11: shows Conjugate A Meningococcal vaccines in Okaikoi Sub metro for various months in 2017, 2018 and the first four months of 2019 .............................................................. 63 Figure 12: shows Measles-Rubella vaccines in Okaikoi Sub metro for various months in 2017, 2018 and the first four months of2019 .................... ..................................................................... 64 ix Figure 13: shows Okaikoi Submetro Conjugate A Meningococcal vaccines issued as compared with the children vaccinated for 201 7 ........................................................................................... 65 Figure 14: differences in Okaikoi Submetro Conjugate A Meningococcal vaccines issued as compared with the children vaccinated for 2018 .......................................................................... 66 Figure 15: Okaikoi Submetro Conjugate A Meningococcal vaccines issued as compared with the children vaccinated for the first ~hree months of 2019 ................................................................. 67 Figure 16: Okaikoi Submetro Measles-Rubella vaccines issued as compared with the children vaccinated for 2017 ....................................................................................................................... 68 Figure 17: Differences in Okaikoi Submetro Measles-Rubella vaccines issued as compared with the children vaccinated for 2018 .............................................. ..................................................... 69 Figure 18: Okaikoi Submetro Measles Rubella vaccines issued as compared with the children vaccinated for the first three months of 2019 ............................................................................... 70 X LIST OF TABLES Table 1: Trend of Measles / Rubella first and second vaccination coverages and dropout rates from 2015 to 2017 ........................................................................................................................... 6 Table 2: Vaccination coverage for Meningococcal Conjugate A vaccine (Men A) compared with second dose of Measles/ Rubella vaccine and Dropout rate for 2017 ............................................ 7 Table 3: List of Child Welfare Clinic points under Kaneshie zone .............................................. 16 Table 4: Independent Variables and meaning ............................................................................... 18 Table 5: Okaikoi Submetro first year of life vaccination coverages and second year of life indicators for 2017 ............. ." .......................................................................................................... 24 Table 6: Okaikoi Submetro first year of life vaccination coverages and second year of life indicators for 2018 ............................................................................. ........................................... 25 Table 7: Okaikoi Submetro first year of life vaccination coverages and second year of life indicators for the first quarter 2019 .............................................................................................. 26 Table 8: Okaikoi Submetro annual performance vaccination coverages of some indicators compared with the percentage difference for 2017 ....................................................................... 29 Table 9: Okaikoi Submetro annual performance vaccination coverages of some indicators compared with the percentage difference for 2018 ....................................................................... 30 Table 10: Okaikoi Submetro annual performance vaccination coverages of some indicators compared with the percentage difference for the first quarter of 2019 ......................................... 31 Table 11: Okaikoi Submetro Area annual performance vaccination coverages of some indicators compared with the target population for 2017 .............................................................................. 32 Table 12: Okaikoi Submetro Area annual performance vaccine coverages of some indicators compared with the target population for 2018 .............................................................................. 33 xi Table 13: Okaikoi Submetro Area annual performance vaccination coverages of some indicators compared with the target population from January to March, 2019 ............................................ . 34 Table 14: Abeka Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ........................................... 35 Table 15: Achimota Outreach Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ............................. 36 Table 16: Akweteman Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ............................. 37 Table 17: Kaneshie Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ........................................... 38 Table 18: Tesano Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ........................................... 39 Table 19: Achimota Hospital Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ............................. 40 Table 20: Kaneshie Polyclinic Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 201 7 ............................. 41 Table 21: Apenkwa Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ........................................... 42 Table 22: Other Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017 ........................................... 43 Table 23: Areas and Zones second year of life population breakdown for Okaikoi Submetro by annual, monthly, weekly and daily target population for 2019 .................................................... 44 xii Table 24: Kaneshie zone performance coverage for the second year of life vaccines from January to March, 2019 ............................................................................................................................. . 45 Table 25: Abeka Zone second year oflife vaccination coverage for the first quarter of 2019 .... 46 Table 26: Achimota CHPS Zone second year of life vaccination coverage for the first quarter of 2019 ............................................................................................................................................... 47 Table 27: Tesano Zone second year of life vaccination coverage for the first quarter of 2019 ... 48 Table 28: Summary staff responses on questionnaires given them for the three months of data collection period April to June 2019 ............................................................. ................................ 50 Table 29: Interviewer observation during the administering of questionnaires on site ................ 51 Table 30: Relationship between staff adequacy, other factors and immediate tallying ................ 52 Table 31: Relationship between staff adequacy, other factors and provision of adequate information .................................................................................................................................... 53 Table 32: Differences in some observations ................................................................................. 54 Table 33: Differences in output levels and shortage of Men A and MR vaccines ....................... 55 Table 34: Differences in output and input (vaccine shortages and 2nd Year of Life policy) ....... 56 Table 35: Cold chain equipment availability in Okaikoi Submetro facilities for 2019 ................ 71 Table 36: Kaneshie zone educational level of participants for focus group discussion in percentage ..................................................................................................................................... 73 Table 37: Achimota zone participants educational level for focus group discussion in percentage ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 73 xiii ACH lYL 2YL CHPS cYMP EPI GHS GPRS KPC MDG MENA MOH MR MRl MR2 MSD NS RCH ABBREVIATIONS ACHIMOTA FIRST YEAR OF LIFE SECOND YEAR OF LIFE COMMWITY-BASED HEALTH PLANNING SERVICES COMPREHENSIVE YEAR MULTI PLAN FOR IMMUNIZATIONS EXPNADED PROGRAM ON IMMUNIZATION GHANA HEALTH SERVICE GHANA POVERTY REDUCTION STRATEGY KANESHIE POLYCLINIC MILLENUIM DEVELOPMENT GOALS MENINGOCOCC AL CONJUGATE AV ACCINE MINISTRY OF HEALTH MEASLES RUBELLA MEASLES RUBELLA FIRST DOSE MEASLES RUBELLA SECOND DOSE MEASLES SECOND DOSE NSAWAM REPRODUCTIVE AND CHILD HEALTH xiv RD PHC U5MR WPV ROAD POPULATION AND HOUSING CENSUS UNDER FIVE YEARS MORTALITY RATE WILD POLIO VIRUS xv 1.1 Background CHAPTER ONE INTRODUCTION Ghana has made a lot of progress m immunization throughout the country culminating in a considerable reduction in morbidities, disabilities and mortalities associated with vaccine­ preventable diseases such as whooping cough, pertussis, yellow fever, poliomyelitis and measles. Immunization , a routine activity within the health sector continues to be one of the key areas within the health system. Accra Metropolis is characterized by a high floating population which outbreak of measles, rubella and meningitis will be a serious public health burden. The measles­ rubella (MR) vaccine protects against measles, rubella and congenital rubella syndrome. Any child who does not receive the first dose of MR vaccine at 9 months is given the vaccine at first contact and the second dose will be provided at 18 months. Meningococcal A Conjugate Vaccine (Men A) protects against Neisseria Meningitis. One dose of the vaccine is administered at 18 months, the same time as second dose measles-rubella vaccination. The life of children under five years is of great concern as they are vulnerable to disease for surviving into older age where immunization is successful. Ghana introduced the second dose of measles in 2012 as the second year of life vaccines given at 18 months. In September 2016 a new second year of life vaccine was added to Meningococcal Conjugate A vaccine (Men A) given at 18 months. The measles vaccination as a single disease was switched to measles-rubella vaccine to cover two diseases which were started in October 2016 (MOH/GHS,WHO, 2016). Even though a lot of effort is still being made to maintain the gains made in the second year of life (2YL) coverages as compared with the first year of life (1 YL) coverages which is low and this obviously is worrying. 1 Ghana is making progressive improvements in the health status of the population. Notwithstanding, the country is confronted with the double burden of disease across all ages and sexes, with non-communicable diseases becoming the major cause of morbidity and mortality alongside the existing and emerging communicable diseases (MOH/GHS ,WHO, 2015). Child health has significantly improved over the years, with the child survival rates increasing as a result of the high impact healthcare services and economic progress . Despite these efforts , one in eleven Ghanaian children dies before their fifth birthday, largely from preventable childhood diseases (MOH/GHS,WHO, 2015). In 2000, Ghana recorded an under-five mortality rate of 167 per 1000 live births that declined to 90 per 1000 live births in 2010, an estimated 46 percent decline. This decline notwithstanding indicates that Ghana although making progress still appears off-track in achieving the MDG 4 target of 39.9 per 1000 live births by 2018, as the progress is slow (PHC, 2013). Variations across the country show that under-five mortality rate (U5MR) is comparatively lower in urban than in rural areas. Accordin g to the 2010 Ghana Population and Housing Census (PHC), U5MR in rural areas is 90 deaths per 1000 live births compared to 83 deaths per 1000 live births in urban areas. Mortality is higher among male children than among female children, comparative U5MR for male and female children in urban areas were 92 and 76 deaths per 1000 live births, respectively. In rural areas, U5MR among male and female children were 98 and 82 deaths per 1000 live births, respectively (PHC, 2013). The implications of such low immunization coverage in a geographical area like Accra which has about 10% of the national population is all too evident. A number of contributory factors such as increased socio-economic development and immunization of children against vaccine-preventable diseases as outlined in the Child Health 2 Policy account for much of the progress made in reducing morbidity and mortality. The country has not recorded any documented death from measles since 2003, and since November 2008 there has not been any report of wild poliovirus (WPV) (MOH/GHS,WHO, 2015). Immunization against vaccine-preventable diseases delineates the one key intervention to be scaled up alongside the continuum of care. This focuses on improving access and quality, as well as increasing the demand for essential services. The introduction of new vaccines such as the 2nd dose measles, pneumococcal and rotavirus vaccines to protect the children under 5 years through the national Expanded Programme on Immunization (EPI) (MOH/GHS,WHO, 2016). An estimated 40 percent of all deaths that occur before the age of five have been found to be associated directly and indirectly with under-nutrition, making it the single most important cause of child mortality. In response, several of initiatives have been implemented since 2007. This was a multi-sectoral strategy that sought to address malnutrition as a developmental problem in the context of the Ghana Poverty Reduction Strategy (GPRS). The health sector has expanded its child health interventions specifically in nutrition services, immunization, vitamin A supplementation and deworming that affect child nutritional and health status, primarily through the rapid delivery approach (MOH/GHS,WHO, 2015). Ghana is confronted with many challenges in child survival, despite a lot of success chalked. The inadequacy of human resources and skills within the health system poses a major obstacle to quality of care especially in the area of neonatal, postnatal and child illnesses. Also, under­ reporting of child deaths and inadequate national data to provide complete and reliable information on child health are major contributors to challenges in delivering child health interventions. 3 Other reviews such as the Ghana Immunization Service Review, 2015; Effective Vaccine Assessment Report 201 O; the Policy on immunization 2016; and the Holistic Assessment of the Health Sector Programme of Work 2016 have identified some systemic bottlenecks to improving and sustaining high immunization coverage including: D Inadequate and poor access to services in hard to reach districts (especially, islands and lake communities). D Inadequate cold chain capacity at lower levels ( about 41 %of fridges and freezers are over IO years). D Weak community engagement and involvement in immunization services. D Weak capacity for micro-planning and logistics management at the sub-district and CHPS zone level. D Poor documentation of primary data which impacts on data quality and. D Inadequate infrastructure. 1.2 Problem Statement Immunization has been going on in Accra metropolis since the late seventies with variable success. Various strategies have been used and this includes static, outreach, house to house, mass immunization and mini mass immunization campaigns. However, for the past three years since the introduction of the second year of life vaccines such as measles /rubella and Meningococcal Conjugate A vaccine (Men A) in the fourth quarter of 2016, there has been an inconsistency in the number of children immunized in the metro as 4 compared with the first year of life vaccines. There is concern about the same second-year vaccination supposed to be given the same time with differences. Even though there has been some attempt to improve, the efforts have not been uniform across the five Submetros. Some of the Submetros are doing quite well at least by minimizing differences between series I and 2 and improved on previous year performance whilst some are not doing so well. It has become necessary to identify reasons for this discrepancy in performance since the flow of funds and other resources have been fairly regular with the view to helping them do the appropriate interventions. 1.3 Justification The data presented in table 1 and 2 explains the differences between MRI, MR2 and Men A immunization coverages which Accra Metropolis were unable to achieve 85% and above for population herd immunity (MRI 78.75%, MR2 69.40% and Men A 71.38%). Okaikoi Submetro in 2017 achieved 96.37% for MRI the highest performance, 78.04% for MR2 and 72.85% for Men A with dropout rate between MR2 and Men A 6.65% given the worse Submetro dropout rate. The population herd immunity status for the second year of life vaccine is paramount to achieving at least 95% of performance coverage. The metropolis inability to meet national performance coverage target is causing more concern about community safety for herd immunity. This can lead to an outbreak of the second year of life vaccine (diseases) to uncompromising level. 5 Table 1: Trend of Measles/ Rubella first and second vaccination coverages and dropout rates from 2015 to 2017. 2017 2015 Cov. 2016 Cov. 2017 Cov. 2015 2016 2017 , Metros Target MRI MR2 MRI MR2 MRI MR2 MRI- DOR MRI- DOR MRI- DOR Pop. MR2 MR2 MR2 ,Iekuma 32369 17805 17477 21110 17275 23130 21245 328 1.84 3835 18.17 1885 8.15 ,shiedu 5543 3663 2574 4592 3551 3658 (eteke 2952 1089 29.73 1041 22.67 706 19.30 yawaso 20954 14860 12721 15472 13112 16411 14712 2139 14.39 2360 15.25 1699 10.35 >kaikoi 14561 11201 9229 11430 8374 13923 11364 1972 17.61 3056 26.74 2559 18.38 1 Klottey 6037 4114 3456 4074 3531 5455 4874 658 15.99 543 13.33 581 10.65 Accra 79464 51643 45457 56678 45843 62577 55147 6186 11.98 10835 19.12 7430 Metro 11.87 Source: Accra Metro Health Directorate Annual Report for Disease Control and Prevention 2017 6 Table 2: Vaccination coverage for Meningococcal Conjugate A vaccine (Men A) compared with second dose of Measles/ Rubella vaccine and Dropout rate for 2017. Sub Metros Target Pop. 2017 MenA %Cov. MR2-MenA DOR Ablekuma 32369 22913 70.79 -1668 -7.85 Ashiedu Keteke 5543 2960 53.40 -8 -0.27 Ayawaso 20954 14424 68.84 288 1.96 Okaikoi 14561 10608 72.85 756 6.65 Osu Klottey 6037 5818 96.37 -944 -19.37 Accra Metro 79464 56723 71.38 -1576 -2.86 Source: Accra Metro Health Directorate Annual Report for Disease Control and Prevention 2017 1.4 Conceptual framework A conceptual framework for the second year of life immunization program in Accra Metropolis . In this framework, annual Sub Metros assessments brought about innovations in the vaccination process. Information obtained on Submetros coverage performance influenced management and motivated health staff to consider alternative interventions to motivate guardians. Depending on available resources and the Submetros population, staff modified Child Welfare Clinics immunization practices, which ultimately led to improved Second Year of Life vaccination coverage by Sub Metros. 7 Submetro ,s "Performance'' Management and Organization of Child Welfare Clinic Population . Staff . Denominator I 1 - Immunization Practices 1 Improved 2YL Immunization Coverage by Submetros + Motivation of Health workers and guardians I Resources i--- Vaccines . Logistics Figure 1: Conceptual Framework for improved Second Year of Life (2YL) Immunization in Accra Metropolis. 1.5 General objective To assess suboptimal second year oflife immunization coverage performance in Okaikoi Sub metro, Accra Metro for 2017. 1.6 Specific objectives 1. To assess annual vaccination coverage from 2017 to the first quarter of 2019. 2. To assess factors that contribute to service providers output. 3. To identify health facilities factors that may lead to low immunization coverage. 4. To assess how parents or clients' factors affect immunization activities. 8 CHAPTER TWO LITERATURE REVIEW 2.1 Vaccination providers in Ghana The Ministry of Health (MoH) provides oversight responsibility of all agencies within the health sector - Ghana Health Service, Teaching Hospitals, Faith-based institutions including Christian Health Association of Ghana (CHAG), Quasi-government health institutions and Private sector. Pneumococcal conjugate vaccine (PCV) and rotavirus vaccine introduced same time as 1 YL vaccine achieving 90% while the second dose of measles-containing vaccine (MCV2) did not rise above 70% (Nyaku et al., 2017). The ultimate goal of the Ghana health sector is to ensure a healthy and productive population that reproduces itself safely. Ghana's National Health Policy (2007) was developed in line with the Primary Health Care Approach and Regional strategies. This provides direction on the national health strategic plans in order to harmonize and align the management and provision of comprehensive essential health services throughout Ghana (MOH/GHS,WHO,UNICEF, 2016). The critical driver for Ghana was to operationalize the Alma Ata goal of "Health for All". (GHS, 2017). Vaccination is a critical pillar in bringing health to children in Ghana where the public and private partnership is paramount in bringing health closer to the door steps of the populace (World Health Organisation, 2003). 2.2 Benefit of vaccination The 2011 Multi-indicator Cluster Survey (MICS 2011) estimated that there were twice as many under-fives dying per 1,000 live births in the poorest wealth quintile in comparison to the richest. The U5MR has reduced in all the regions in Ghana with the largest decline recorded in the Greater Accra region, reducing by about 100 percent, 72 deaths per 1,000 live births (GSS; GHS; ICF International, 2015; PHC, 2013). Poverty is a major contributor to the probability of a child 9 dying before the age of five years. It has been estimated that without immunization 3% of all children will die from measles (MOH/GHS,WHO, 2015) . The national Infant Mortality Rate (IMR) has also declined over time. The IMR dropped from 90 deaths per 1000 live births in 2000 to 59 deaths per 1000 live births (PHC, 2013). In the (GSS; GHS; ICF International, 2015), however IMR was 50 per 1000 live births over the survey period. Again, although there has been suhstantial progress towards achieving the MDG target of 26 per 1000 live births by 2015, to actually achieve this target remains a major challenge. Ghana recognizes the urgent need for primary health care for all its citizens in order to expand preventive and rehabilitative as well as curative care. Meningococcal disease case fatality among children 1-4 years in the USA is 15.2% (Pieterse, 2004). The country adopted an evidence-based primary strategy to reach the unreached, essentially recognizing the role of households in achieving the national health goals. This call for bridging geographical access gaps in order to bring basic yet essential health services to communities, while making up for the gap in human resources for health and augmenting their capacities. 2.3 CHPS concept and immunization Ghana's community-based health planning and services (CHPS) approach is the national strategy for addressing these gaps in access to quality health services at the community level. CHPS is equity-focused and has an implementation modality that has the strong support of the government and development partners in the health sector. Through the CHPS close-to-client approach, there have been significant reductions in immunization dropout rates and improvements in coverage, service accessibility, and quality of maternal and family planning care essentially bridging the access gap between communities and health facilities (GHS , 2017). The CHPS is thus recognized as the lowest level of health service delivery in the health sector. 10 The sub-district level comprises of health centers, which serve as the next referral level after CHPS and provide oversight to CHPS. The training provided for community health training nurses as CHO,s was well understood in providing urban CHPS (Nwameme, Tabong, & Adongo, 2018). 2.4 District immunization focus The District Health Services (Management Teams) have been empowered to take on full oversight responsibilities to ensure that all public health initiatives (implementation activities) are organized and synchronized in collaboration with other sectors particularly District Assemblies. This set pace for-one of the current strengths of the country's routine immunization system as well as national campaigns, which augment routine efforts. The Government continues its commitment to financing immunizations nationally and no one is required to pay for childhood vaccines. Several innovative strategies are used to deliver immunization services. Static immunization is the main service delivery strategy. Every health facility has a static clinic responsible for daily routine immunizations. The increasing availability of such clinics in the country has made access to routine immunization easier. Outreach immunization services are organized to reach children in communities where static clinics are not available. The outreach programme has contributed immensely towards bridging the gap between communities with health facilities and those who do not have. Thus, increasing access to EPI services to all eligible children and women. Mop-ups are also done in areas with low coverage and difficult to reach areas (areas not accessible during the rainy season) with the aim of reaching every child. Transit point vaccination including vaccination s done at Lorry parks, markets, churches, mosques etc. is also used. When necessary, mass vaccinations are conducted to reach out to specific groups. 11 Ghana successfully introduced four new vaccines in 2012. Three of these vaccines (measles second dose (MSD), Rota Virus Vaccine and Pneumococcal Vaccines) were introduced into the routine immunization program. The fourth one, which is Men A was introduced in a campaign mode in the three regions in the North, targeting the age group 1-29 years. In 2013, Ghana received support for HPV demonstration in four districts. The country also introduced the Measles-Rubella (MR) vaccine intn the routine immunization program. The uptake of these new vaccines has been satisfactory except MSD. 2.5 Immunization programme in Ghana The country has good experience with regards to the introduction of new vaccines into routine immunization as well as deploying new vaccines through mass vaccination. There are well­ organized structures as well as competent staff to guide the introduction of new vaccines. Technical expertise is drawn from both within and outside of the EPI Programme. There are established committees that take care of all the technical elements which are common to any new vaccine introduction. These committees include cold chain, training and service delivery, logistics and waste management, surveillance, communication. In the area of advocacy, communication and social mobilization, previous introductions have shown that adequate public education and high-level advocacy contributed to the acceptance of new vaccines by the general population. Development, printing and dissemination of fact sheets also help service providers to know what and how to communicate to the public. Development of training plan and training materials enabled facilitators at all levels to conduct standardized trainings. Cascaded training ensured all levels were trained on all aspects of vaccine introductions. Early revision and printing of data collection tools in the previous introduction 12 was found to be very important. Portions were created in the existing data collection tools for new vaccines. This ensured the recording and reporting of performance of new vaccines . Experience in vaccine introductions has shown that critical attention must be paid to cold chain availability, requirements and plans for improvements where necessary. Every new vaccine has an impact on cold chain requirement. Fortunately for Ghana, the recent introduction of vaccines for pneumonia and diarrhea led to an expansion of the cold chain capacity nationwide. However, there are some deficits, especially, at the national, district and facility levels. In previous introductions, the existing surveillance systems for the disease of interest were enhanced. In addition, special adverse event surveillance systems were set up to monitor any event reported after administration of the vaccine. Monitoring and supervision was also a key component of previous introductions. The country also introduce d peer-monitoring and reviews among regions for best practices to be shared and bad practices avoided . 2.6 Urban Immunization in Ghana Immunization in metropolitan and cosmopolitan areas in Ghana is a huge challenge with the rate of migration from the rural to urban areas which is of great concern. There is no definition for a city which is greater than a town. GHS, the MoH and in-country stakeholders are implementing measures to further identify and target the needs and challenges of urban poor and addressing low immunization coverage among urban communities . These measures include: mapping of urban and peri-urban slums, establishing container clinics at markets within urban poor areas, and conducting market and weekend vaccination sessions. Ongoing efforts include engagement of community structures through durbars, market queens, and in some cases, use of radio. With support from the US Centers for Disease Control and in close collaboration with GHS and the private sector, container clinics are in use as part of 2YL interventions in metropolitan areas 13 (WHO/UNICEF, 2017). The country's urban population grew more than three-fold between 1984 and 2014 (PHC, 2013), increasing the number of under-immunized children in these areas. 2.7 Mixed opportunities in vaccination Today we are vaccinating more children than ever, yet millions of children still miss out on routine vaccinations. National immunization programmes continue to seek evidence-based strategies to understand the underlying reasons and to design tailored approaches to address them. Using a participatory mixed-methods approach, the MOV strategy provides step-by-step guidance on how to conduct a bottom-up root-cause analysis of bottle-necks in the immunization programme and to implement relevant interventions to address them (Shendale, 20 19). The MOV strategy should not be viewed as a stand-alone or discrete "project"; rather as complementary to existing microplanning and programme improvement approaches such as RED ('Reaching Every District'). The MOV strategy is conceived as a health system-wide service improvement effort targeted at improving vaccination as well as other health services within a given health facility (Shendale, 201 9). 14 3.1 Study Area CHAPTER THREE METHODS The study area was Okaikoi Submetro with two areas namely the Kaneshie zone and Achimota zone. This is well-populated areas especially Kaneshie area and is inhabited by a wide diversity of ethnic groups from all parts of Ghana and beyond. Map Showing Study Area Legend C=:J Okaikoi Sub Metro - Accra Metro - Greater Accra Region 0 0 20 40 Kilometes Figure 2: Shows the map of study area Okaikoi Sub Metro within Greater Accra and Accra Metropolis. 15 Table 3: List of Child Welfare Clinic points under Kaneshie zone Lapaz Community Hospital Ayigbe Town Pentecost Church New Market Rabenrich Maternity Bambolino Kantsian Motorway Lapaz Holy Trinity Hospital Transformer/Accra Station Lakeside Clinic Nkordaasusua Baptist Church Kaneshie Market Hobat Clinic Pentecost Church Blessing Clinic Akotu Junction Apenkwa Kaneshie Polyclinic Emmanuel Clinic Ankam Hospital Methodist Church/ Abeka Market P.O.P Maternity Home Adorn Herbal Night Market Modem Care Hospital Chief Imam Opman Clinic International Trinity Church Abotre/ Post Office Ante Korkor A venor Proper Pentecost Church Avenor Rails Light House Mission/ Theresa Maternity Church of Christ A venor Demod Assemblies of God Church/ Busanga Lane Achimota Market Atico SDA Church Kopevi Alogboshie Aveuor CHPS . . Source: Kanesh1e polychmc Pubhc Health Nursmg Umt . 16 List of Child Welfare Clinic points in Achimota Zone • Abofu CHPS • Achimota Hospital • Achimota Market CHPS • Achimota School Clinic • Achimota Transport Terminal Clinic • Alogboshie CHPS • Anumle CHPS • Central Achimota Clinic CHPS • Christian Village CHPS • Kisseman CHPS • Midway Clinic 3.2 Study Population Health workers, health facilities and guard ians of vaccinees. 3.3 Study type and design A mixed method comprising of a qualitative and a quantitative study. Cross sectional study design . 3.4 Variables 3.4.1 Dependent variable Second-year of life immunization coverage performance m Okaikoi Submetro m Accra Metropolitan area. 17 Table 4: Independent Variables and meaning Independent Variables Meaning The way vaccination is carried out by Operational Strategies community health nurses Taking of vaccines on charge in Vaccine Ledger Vaccines availability and adequacy Books with maintaining minimum and maximum stock level Needles and syringes availability and Taking charge of Needles and syringes received adequacy from Metro Stores into ledger books Tally book availability and adequacy Taking stock oflmmunization tally books in use Taken inventory of cold chain equipment and its Cold chain availability and adequacy function ability Availability of planned schedule for child Planning for child welfare clinics welfare clinics by Nurses Mode of transportation and how nurses reach Transport itinerary availability child welfare clinics How vaccines and other items needed for Logistics release arrangements successful child welfare clinic is released Time Community Health Nurses set off to child Time of departure for outreach welfare clinic and start work 18 Table 4: Independent Variables and meaning continues Independent Variables Meaning Observing Public Health Nurses supervision Supervision of nurses schedule, conduct and reports on it Observation of an environment where Assessment of immunization sites and immunization is carried out and manner they quality of service carried out their duties Staff to express challenges that hinders their Problems encountered at outreach point~ performance expected from them Tally book entries and tallying Observe correct use of immunization registers Tally book records and returns submitted Checking of returns with entries into DHIMS compatibility How staff and community members prepare for Community mobilization arrangements immunization session Mothers' perception on the second year of Guardians interpretation of the second year of life immunization life immunization Knowledge of mothers on the second year What staff tell them about the second year of life of life immunization immunization 19 3.5 Sample size 169 respondents minimum comprising of Facility heads, Public Health Nurses, Disease Control Officers and Community Health Nurses using finite population formula. Nz2pq n=-------- d2 (N - 1) + z 2 pq N=200 z=l.96 p =0.5 (50%) d = 0.03 (3%) n = 169 minimum The focus group discussion involved 18 mothers which 9 women were recruited at each zone namely Kaneshie and Achimo ta. 3.6 Sampling method Purposive sampling was used to identify study samples at the facility level and these include heads of institutions, Public Health nursing officers, disease control officers, community health officers and women in the communities. Selection of mothers in the community for a focus group discussion was based on a set of criteria which included age group between twenty and thirty-five and having a child age more than 18 months as well as attend child welfare clinics during the day of conducting focus group discussion. This was done with the assistance of nursing officers in charge of child welfare clinics. 20 3. 7 Data collection The collection involved interviews using structured questionnaires for the heads, nursing officers and community health nurses directly involved in immunization activities in the facilities. The community health nurses were visited in their respective outreach points to administer the questionnaire. A checklist was used to check on logistics availability, and this included vaccines, child health records, needles and syringes and tally registers from the disease control officers. Another checklist was also used to observe community health nurses carrying out immunization activities at outreach and static clinics. There were record reviews of vaccination data submitted on returns and tally registers and comparison made to check for accuracy. A checklist was used to gather relevant data. Observation of logistics and site of child welfare clinic was done with vaccination coverages. Two separate focus group discussion were conducted which 21 mothers who had more than a child participating. 3.8 Data analysis and processing The quantitative data collected was entered into a computer using Epi Info 7 software after which it was exported into Stata version 15.1 software for labelling and analysis. Respondents' output was generated by creating a composite score ( on a percentage scale) of the variables that served as indicators for output, where 0% indicated poor/none and 100% for the highest output score. Results were presented using tables with frequencies and percentages for the descriptive. Means and standard deviations were also used to show average output levels across some factors. Chi-square tests were used for bivariate associations between categorical variables and Fisher's exact tests used in instances where the assumptions underlying Chi-square failed (i.e. low expected cell frequencies). Wilcoxon rank-sum test was also used to investigate if significant 21 differences in output levels existed between facilities that had a shortage of vaccines and those that didn't. Nvivo, was used for qualitative analysis of interview conducted during focus group discussion which was coded, edited and entered to identify reasons for missing the second series of measles­ rubella vaccination and that of Men A. 3.9 Ethical consideration Consent of heads of health facilities as well as community members (guardians) was elicited before the project was carried out. Data was handled in a professional manner to ensure confidentiality. The Community Health Nurses information was kept confidential in order not to have challenges with the supervisors of Public Health Nurses. The inventory that was taken will not be used to prosecute the officer in charge in the case for any differences observed. The facilities conditions in which they carried out Child Welfare Clinics was not implicated in any manner. The guardians of vaccinees information were kept in confidential and used for the purpose of improvement of services but not for the prosecution of any health worker or facility. 22 CHAPTER FOUR RESULTS Vaccination coverages and vaccines used remains a challenge to EPI managers as there are always discrepancies between the two and this study shows the same. The number of doses received, the children vaccinated and the data reported shows about 68% wastage rate or even negative 32% wastage rate which should not have been the case if documentation is taken seriously. 4.1 Coverages The table 5 shows, Penta 3 children vaccinated for the year 2017 as compared with children vaccinated for MRI, MR2 and Men A. The children vaccinat ed for Penta 3 at 14 weeks were expected to be vaccinated for MRI at 9 to 17 months but 1463 children were missed . 2389 children vaccinated for MRI could not be vaccinated for MR2 between 18 to 59 months. About 1238 children vaccinated for MR2 could not be vaccinated for Men A at the same session and day. 23 Table 5: Okaikoi Submetro first year of life vaccination coverages and second year of life indicators for 2017 Months Penta 3 MRI MR2 Men A January 1107 1142 895 675 February 1158 969 882 797 March 888 918 527 442 April 1089 871 781 641 May 1431 1267 1115 1090 June 809 1031 807 825 July 1347 1120 914 899 August 1538 1378 1111 1124 September 1453 1350 1075 884 October 1471 1325 1119 787 November 1436 1136 1000 957 December 1325 1082 974 841 Total 15052 13589 11200 9962 Source: Kaneshie polyclinic RCH Unit database. Table 6, below shows Penta 3 vaccination coverage of 16898 for 2018 which same were expected for MRI but 2342 children were missed. About 2160 children were missed for MR2 as compared with MRI and 4502 children missed as compared with Penta 3. 899 children were missed for Men A as compared to MR2 given the same time per EPI schedule. 24 Table 6: Okaikoi Submetro first year of life vaccination coverages and second year of life indicators for 2018. Months Penta 3 MRl MR2 MenA January 1434 1280 1047 1051 February 1378 1250 1027 1227 March 1521 1235 1003 1015 April 1551 1251 1072 906 May 1531 1337 1152 914 June 1479 1139 989 600 July 1415 1121 866 750 August 1606 1209 972 955 September 1333 1206 1008 1022 October 1326 1120 1029 957 November 1172 1197 1117 986 December 1152 1211 1114 1114 Total 16898 14556 12396 11497 Source: Kaneshie polyclinic RCH Unit database. Table 7, shows three-month performance coverage for Penta 3, MRl, MR2 and Men A for 2019. About 86 children were vaccinated for MRl which were missed for Penta 3. MR 2 and Men A recorded no difference which is ideal. 25 Table 7: Okaikoi Submetro first year of life vaccination coverages and second year of life indicators for the first quarter 2019. Months Penta 3 MRI MR2 Men A January 1235 1258 1220 1220 February 1225 1195 1151 1151 March 501 594 529 529 Total 2961 3047 2900 2900 Source: Kaneshie polyclinic RCH Unit database. The figure 3, below shows percentage annual performance of Penta 3, MRI, MR2 and Men A for 2017 and 2018. Penta 3 achieved the annual target set of 100% for the two years but there was an increase in performance 2018 than 2017. MR I coverages for 201 7 could not meet the target of 95% set but 2018 has increased in performance more than the target. 2018 performance for MR2 is better than the prev ious year 2107 but both could not achieve the annual target. Men A performance was worse performing indicator in both years with coverage below 70%. 26 120 113 .18 100 LIJ l!) <( 0:: 80 LIJ > 68 .4168 .05 0 u -e 60 LIJ l!) z 40 LIJ u 0:: LIJ Q. 20 0 Penta 3 MRl MR2 Men A 2017 2018 Figure 3: Okaikoi Submetro annual percentage performance for some antigens for 2017 and Figure 4, below shows three years first quarters coverage performance of the expected 25% coverages to achieve the annual target of 100%. 2019 performed poorly as compared with the previous two years in all indicators. To achieve the annual target for Penta 3, MRl, MR2 and Men A, Submetro need to make up for about 14% in the rest of quarters left and maintain at least 25% coverages for the rest three quarters . The 2018 year performed better in all indicators as compared with the rest of the years but could not meet the target of 25% for MR2 and Men A. 27 35 30 29.02 w 25.22 l!) 20.61 0 u 20 i w l!:I 15 2 w u 10 a:: w C. 5 0 Penta 3 MRl MR2 Men A 2017 2018 2019 Figure 4: Okaikoi Submetro annual percentage performance for some antigens for first the quarter of 2017 to 2019. 28 Table 8: Okaikoi Submetro annual performance vaccination coverages of some indicators compared with the percentage difference for 2017. Months Penta 3- % MR 1- % MR2- % Penta 3- % MRI Diff. MR2 Diff. Men A Diff. Men A Diff. January -35 -3.16 247 21.63 220 24.58 432 39.02 February 189 16.32 87 8.98 85 9.64 361 31.17 March -30 -3.38 391 42.59 85 16.13 446 50.23 April 218 20.02 90 10.33 140 17.93 448 41.14 May 164 11.46 152 12.00 25 2.24 341 23.83 June -222 -27.44 224 21.73 -18 -2.23 -16 -1.98 July 227 16.85 206 18.39 15 1.64 448 33.26 August 160 10.40 267 19.38 -13 -1.17 414 26.92 September 103 7.09 275 20.37 191 17.77 569 39.16 October 146 9.93 206 15.55 332 29.67 684 46.50 November 300 20.89 136 11.97 43 4.30 479 33.36 December 243 18.34 108 9.98 133 13.66 484 36.53 Table 8, above shows monthly differences in some indicators which are expected to be within O to 10%. The differences that shows negative are not expected since some were given the same time or day. Penta 3 against MR 1 highest negative coverage was in June with 27.44%, the highest positive coverage of 20.89% in November and months of September and October recorded as expected 7.09% and 9.93% respectively. The highest difference in MR 1 against MR 2 was in March with 42.49%, there were no negative recorded and only February and 29 December normal of 8.98% and 9.98% respectively. The difference in MR 2 and Men A shows 2 negatives with highest in June -2.23%, October been highest positive 29.67% and three months below 10%. Table 9: Okaikoi Submetro annual performance vaccination coverages of some indicators compared with the percentage difference for 2018. Months Penta 3- % Diff. MR l-MR2 % Diff. MR 2- %Diff. Penta 3- % Diff. MRI Men A Men A January 154 10.74 233 18.20 -4 -0.38 383 26.71 February 128 9.29 223 17.84 -200 -19.47 151 10.96 March 286 18.80 232 18.79 -12 -1.20 506 33.27 April 300 19.34 179 14.31 166 15.49 645 41.59 May 194 12.67 185 13.84 238 20.66 617 40.30 June 340 22.99 150 13.17 389 39.33 879 59.43 July 294 20.78 255 22.75 116 13.39 665 47.00 August 397 24.72 237 19.60 17 1.75 651 40.54 September 127 9.53 198 16.42 -14 -1.39 311 23.33 October 206 15.54 91 8.13 72 7.00 369 27.83 November -25 -2.13 80 6.68 131 11.73 186 15.87 December -59 -5.12 97 8.01 0 0.00 38 3.30 Table 9, above shows almost the same pattern as table 6 with differences not within Oto 10% for most of the months. The annual difference between MR 2 and Men A was 5401 representing 30 31.96% which were expected to be zero (0). The highest difference was seen in June for Penta 3 and Men A with 59.43%. Table 50: Okaikoi Submetro annual performance vaccination coverages of some indicators compared with the percentage difference for the first quarter of 2019. Months January February March Penta MRI -23 30 -93 3- %Diff. -1.86 2.45 -18.56 MR 1- %Diff. MR2 38 3.02 44 3.68 65 10.94 MR 2- %Diff. Penta 3- %Diff. Men A Men A 0 0.00 15 1.21 0 0.00 74 6.04 0 0.00 -28 -5.59 Table 10, above shows first quarter 2019 differences which MR2 and Men A achieved expected Zero (0) for the three months. The difference between Penta 3 and MRI for the first quarter was -2.90 which did not fall in expected 0 to 10%. 31 Table 11: Okaikoi Submetro Area annual performance vaccination coverages of some indicators compared with the target population for 2017. AREAS Target Pop. Penta 3 MRI MR2 MenA ABEKA 3975 5027 4389 3846 3357 ACH OUT'RCH 1499 1504 1597 1097 1053 AKWETEMAN 874 535 582 476 426 KANESHIE 2787 3913 3230 2801 2378 TESANO 1078 492 432 376 329 ACHIMOTA HOSP 1101 1616 1255 947 979 KANESHIE P/C 1874 1171 754 488 419 APENKWA CHPS 204 135 180 159 192 OTHERCHPS 1171 996 1169 1010 829 OKAIKOI 14561 15389 13588 11200 9962 Table 11, above shows areas target expected performance as compared with their actual annual coverage for 2017. The annual expected children to vaccinate in achieving 100% was I 456 I and achieved by exceeding with 828 for Penta 3. The MRI missed 973 children , MR2 missed 3361 children and Men A missed more children than all for the review year indicators with 4599. 32 Table 62: Okaikoi Submetro Area annual performance vaccine coverages of some indicators compared with the target population for 2018. AREAS Target Pop. Penta 3 MRI MR2 Men A KANESHIE 1 & 2 CHPS 672 237 426 389 448 BUBIASHIE CHPS 1567 898 1040 940 989 NORTH KANESHIE 1344 1257 1426 1290 1252 *KPC STATIC 896 1356 959 702 642 ABEKA CHPS 1433 858 1000 896 893 FADAMACHPS 1344 2887 1970 1667 1522 NIIBOI CHPS 1702 4367 2742 2687 2138 AKWETEMAN CHPS 746 545 650 564 531 * ACH. NS. RD. CHPS 672 530 597 483 506 *ACH. HOSP CHPS 1344 677 882 640 541 ACHIMOTA STATIC 2463 2219 1651 1091 1188 TESANOCHPS 291 684 564 491 408 AVENORCHPS 351 197 261 211 167 APENKW A CHPS 105 184 167 188 178 OKAIKOI 14930 16896 14335 12239 11403 *KPC- Kaneshie Polyclinic, ACH. NS. RD. -Achimota Nsawam Road, ACH HOSP-Achimota Hospital. Table 12, above shows expected annual target of 14930 which MR 1, MR2 and Men A could not achieve the target but Penta 3 exceeded the target with 1966. MRl missed 595 children not vaccinated for the year reviewed. Children missed for MR2 were 2691 and 3527 for Men A. 33 Table 73: Okaikoi Submetro Area annual performance vaccination coverages of some indicators compared with the target population from January to March, 2019. AREAS Target Pop. Penta 3 MRI MR2 Men A KANESHIE 1 & 2 CHPS 689 50 142 161 161 BUBIASHIE CHPS 1607 226 286 288 288 NORTH KANESHIE CHPS 1377 329 344 408 408 KANESHIE ZONE 3673 605 772 857 857 KPC STATIC 918 394 268 226 226 ABEKACHPS 1468 175 283 250 250 FADAMACHPS 1378 288 272 250 250 NIIBOI CHPS 1745 607 469 454 454 ABEKAZONE 4591 1070 1024 954 954 AKWETEMAN CHPS 765 207 187 172 172 ACH NS RD CHPS 689 84 117 86 86 KISSIEMAN CHPS 230 10 15 17 17 *CHRIST . VILLAGE CHPS 230 8 15 16 16 ABOFU CHPS 2981 10 12 10 10 ANUMLECHPS 0 10 21 10 10 ACHIMOTA CHPS 3441 38 63 53 53 ACH HOSP STATIC 765 356 361 296 296 APENKWA CHPS 0 32 52 48 48 TESANO CHPS 15302 140 128 130 130 AVENORCHPS 0 35 75 78 78 TESANOZONE 15302 207 255 256 256 OKAIKOI 30144 4881 5161 5020 5020 *CHRIST. VILLAGE - Christian Village. Table 13, above shows annual target children to be vaccinated at 30144. The quarterly expected coverage was 7536 all the indicators for review could not achieve. Penta 3 children missed was 34 2655, MRI missed children was 2375 and MR2 and Men A missed a same number of children 2516. Table 14, below shows monthly expected children for vaccination as 331, weekly 83 and daily 28 for MR2 and Men A. The Abeka area achieved 95% target of children vaccinated for MR2 (3842) representing 96.65% and could not achieve same for Men A (3357) children vaccinated representing 84.45%. Table 84: Abeka Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY Men A %COY January 331 83 28 272 82.18 192 58.01 February 331 83 28 323 97.58 323 97.58 March 331 83 28 62 18.73 62 18.73 April 331 83 28 246 74.32 191 57.70 May 331 83 28 364 109.97 338 102.11 June 331 83 28 271 81.87 265 80.06 July 331 83 28 382 115.41 362 109.37 August 331 83 28 445 134.44 445 134.44 September 331 83 28 350 105.74 273 82.48 October 331 83 28 335 101.21 274 82.78 November 331 83 28 413 124.77 314 94.86 December 331 83 28 379 114.50 318 96.07 MTP- Monthly target population, WTP-Weekly target population, DTP-Daily target population 35 Table 15, below shows the monthly target of 125, the weekly target of 31 and the daily target of 10 for children vaccination in Achimota Outreach area. The area could not achieve a 95% target for the year. They vaccinated 1097 children for MR2 representing 73 .18% and for Men A vaccinated 1053 children representing 70.25%. Table 95: Achimota Outreach Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY Men A %COY January 125 31 10 117 93.60 106 84.80 February 125 31 10 92 73.60 111 88.80 March 125 31 10 60 48.00 51 40.80 April 125 31 10 107 85.60 98 78.40 May 125 31 10 113 90.40 93 74.40 June 125 31 10 119 95.20 113 90.40 July 125 31 10 72 57.60 72 57.60 August 125 31 10 88 70.40 97 77.60 September 125 31 10 87 69.60 82 65.60 October 125 31 10 95 76.00 76 60.80 November 125 31 10 87 69.60 111 88.80 December 125 31 10 60 48.00 43 34.40 Table 16, below shows Akweteman Area expected children for vaccination monthly 73, weekly 18 and daily 6 to achieve the annual target. They could not achieve the set target for various 36 months. They vaccinated 476 for MR2 representing 54.48% and vaccinated 426 for Men A representing 48.76% for the year. Table 106: Akweteman Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY Men A ¾COY January 73 18 6 58 79.45 27 36.99 February 73 18 6 34 46.58 39 53.42 March 73 18 6 46 63.01 46 63.01 April 73 18 6 34 46.58 34 46.58 May 73 18 6 48 65.75 48 65.75 June 73 18 6 36 49.32 36 49.32 July 73 18 6 28 38.36 28 38.36 August 73 18 6 30 41.10 30 41.10 September 73 18 6 31 42.47 22 30.14 October 73 18 6 51 69.86 43 58.90 November 73 18 6 38 52.05 32 43.84 December 73 18 6 42 57.53 41 56.16 Table 17, shows Kaneshie Area monthly coverage of 232, weekly 58 and daily 19 to achieve the annual target. They were able to achieve 100% and more for the month of May, September, October and December. They achieved the target for MR2 by vaccinating 2801 children representing 100.51 % but could not for Men A by vaccinating 2378 children representing 85.33%. 37 Table 117: Kaneshie Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY Men A %COY January 232 58 19 210 90.52 153 65.95 February 232 58 19 231 99.57 145 62.50 March 232 58 19 180 77.59 146 62.93 April 232 58 19 157 67.67 134 57.76 May 232 58 19 263 113.36 289 124.57 June 232 58 19 181 78.02 205 88.36 July 232 58 19 221 95.26 229 98.71 August 232 58 19 229 98.71 229 98.71 September 232 58 19 335 144.40 282 121 .55 October 232 58 19 350 150.86 153 65.95 November 232 58 19 210 90.52 210 90.52 December 232 58 19 234 100.86 203 87.50 Table 18, below enumerated the monthly target of 90 children, the weekly target of 23 children and the daily target of 8 children when vaccinated by Tesano Area will achieve the set target of 95% for the year. They were able to vaccinate 376 children for MR2 representing 34.89% and for Men A vaccinated 329 children representing 30.53%. 38 Table 128: Tesano Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY Men A %COY January 90 23 8 33 36.67 21 23.33 February 90 23 8 24 26.67 24 26.67 March 90 23 8 17 18.89 17 18.89 April 90 23 8 22 24.44 22 24.44 May 90 23 8 35 38.89 28 31.11 June 90 23 8 23 25.56 23 25.56 July 90 23 8 34 37.78 29 32.22 August 90 23 8 43 47.78 43 47.78 September 90 23 8 31 34.44 4 4.44 October 90 23 8 25 27.78 20 22.22 November 90 23 8 50 55.56 57 63.33 December 90 23 8 39 43.33 41 45.56 Table 19, shows Achimota Hospital Area annual target coverage breakdown by monthly, weekly and daily 92,23 and 8 respectively. They were able to achieve 100% and above in some four months namely April, May, August and September. They were not able to achieve the set target by vaccinating 947 children representing 86.03% for MR2 and Men A vaccinated 979 (88.94). 39 Table 19: Achimota Hospital Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY Men A %COY January 92 23 8 70 76.09 80 86.96 February 92 23 8 80 86.96 80 86.96 March 92 23 8 40 43.48 40 43.48 April 92 23 8 97 105.43 97 105.43 May 92 23 8 140 152.17 150 163.04 June 92 23 8 58 63.04 57 61.96 July 92 23 8 58 63.04 74 80.43 August 92 23 8 100 108.70 100 108.70 September 92 23 8 100 108.70 100 108.70 October 92 23 8 76 82.61 73 79.35 November 92 23 8 59 64.13 59 64.13 December 92 23 8 69 75.00 69 75.00 Table 20, shows Kaneshie Polyclinic Area monthly performance for the second year of life vaccination. The monthly children vaccinated 156, weekly 39 and daily 13 could make the area achieve set target for the year. They were able to vaccinate 488 (26.04%) children for MR2 and 419 (22.36%) for Men A as annual coverage. 40 Table 130: Kaneshie Polyclinic Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY Men A %COY January 156 39 13 53 33.97 27 17.31 February 156 39 13 27 17.31 27 17.31 March 156 39 13 49 31.41 49 31.41 April 156 39 13 34 21.79 20 12.82 May 156 39 13 36 23.08 36 23.08 June 156 39 13 28 17.95 31 19.87 July 156 39 13 16 10.26 8 5.13 August 156 39 13 70 44.87 75 48.08 September 156 39 13 33 21.15 24 15.38 October 156 39 13 44 28.21 32 20.51 November 156 39 13 43 27.56 49 31.41 December 156 39 13 55 35.26 41 26.28 Table 21, below shows Apenkwa CHPS Area monthly performance for the second year of life vaccines. It was expected that for every CWC session in the month they will vaccinate 17 children, 4 children weekly and 1 child a day. They could not achieve the target of 95% but Men A was close with 94.19% by vaccinating 192 children and MR2 children vaccinated were 159 (78%). 41 Table 141: Apenkwa Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 %COY MenA %COY January 17 4 1 18 105.88 18 105.88 February 17 4 1 8 47.06 8 47.06 March 17 4 1 9 52.94 9 52.94 April 17 4 1 18 105.88 18 105.88 May 17 4 1 14 82.35 12 70.59 June 17 4 1 9 52.94 17 100.00 July 17 4 1 7 41.18 8 47.06 August 17 4 1 14 82.35 15 88.24 September 17 4 1 18 105.88 18 105.88 October 17 4 1 24 141.18 31 182.35 November 17 4 1 12 70.59 26 152.94 December 17 4 1 8 47.06 12 70.59 Table 22, shows Other CHPS Area monthly coverage for MR2 and Men A. The area was expected to vaccinate 98 children monthly, vaccinate 25 children monthly and vaccinate 8 children daily to achieve at least 95% coverage. They vaccinated 829(70.81 %) children for Men A and vaccinated 1010 (86.27%) children for MR2. 42 Table 22: Other Area second year of life vaccination coverages compared with the monthly target population, showing the weekly and the daily target for 2017. Months MTP WTP DTP MR2 ¾COV Men A ¾COV January 98 25 8 60 61.22 51 52.04 February 98 25 8 63 64.29 40 40.82 March 98 25 8 64 65.31 22 22.45 April 98 25 8 66 67.35 27 27.55 May 98 25 8 102 104.08 96 97.96 June 98 25 8 82 83.67 78 79.59 July 98 25 8 96 97.96 89 90.82 August 98 25 8 92 93.88 90 91.84 September 98 25 8 90 91.84 79 80.61 October 98 25 8 119 121.43 85 86.73 November 98 25 8 88 89.80 99 101.02 December 98 25 8 88 89.80 73 74.49 Table 23, shows below a breakdown of the target population for Okaikoi Submetro for 2019 at the end of the year to vaccinate 30144 children with Measles-Rubella second doses and Conjugate Meningococcal A vaccine to achieve 100% coverage. The estimated target population were not given to three of the areas namely Anumle CHPS, Apenkwa CHPS and A venor CHPS zones. The target for monthly children to be vaccinated is 2512, the weekly target is 628 and the daily target is 209. The Okaikoi Submetro holds at least 14 Child Welfare Clinics a day in 43 various areas which needed 15 children vaccinated at all site if the population is the same. The variation in the population of areas shows least target for a day is 2 and highest is 21. Table 153: Areas and Zones second year of life population breakdown for Okaikoi Submetro by annual, monthly, weekly and daily target population for 2019 Areas ATP MTP WTP DTP KANESHIE 1 & 2 CHPS 689 57 14 5 BUBIASHIE CHPS 1607 134 33 11 NORTH KANESHIE CHPS 1377 115 29 10 KANESHIE ZONE 3673 306 77 26 KPC STATIC 918 77 19 6 ABEKACHPS 1468 122 31 10 FADAMACHPS 1378 115 29 10 NIIBOI CHPS 1745 145 36 12 ABEKAZONE 4591 383 96 32 AKWETEMAN CHPS 765 64 16 5 ACH NS RD CHPS 689 57 14 5 KISSIEMAN CHPS 230 19 5 2 CHRISTIAN VILLAGE CHPS 230 19 5 2 ABOFU CHPS 2981 248 62 21 ANUMLECHPS 0 0 0 0 ACHIMOTA ZONE 3441 287 72 24 ACH HOSP STATIC 765 64 16 5 APENKWA CHPS 0 0 0 0 TESANO CHPS 15302 1275 319 106 AVENORCHPS 0 0 0 0 TESANOZONE 15302 1275 319 106 OKAIKOI 30144 2512 628 209 Source: RCH Unit, Kaneshie polyclinic 44 Table 24, below shows 2019 first-quarter performance for the second year of life vaccines by month. The zone was able to vaccinate 857 (93.33%) for MR2 and Men A which fall short of 1.67% in achieving the target of 95%. North Kaneshie CHPS was able to achieve 100% and above within the areas. They were no differences between MR2 and Men A as an ideal. Table 164: Kaneshie zone performance coverage for the second year of life vaccines from January to March, 2019. AREAS/ ZONES Indicators January February March First Quarter Kaneshie 1 & 2 CHPS MR2 60 64 37 161 %COY 104.50 111.47 64.44 93.47 Men A 60 64 37 161 %COY 104.50 111.47 64.44 93.47 BUBIASHIE CHPS MR2 94 95 99 288 %COY 70.19 70.94 73.93 71.69 Men A 94 95 99 288 %COY 70.19 70.94 73.93 71.69 NORTH KANESHIE CHPS MR2 91 170 147 408 %COY 79.30 148.15 128.10 118.52 Men A 91 170 147 408 %COY 79.30 148.15 128.10 118.52 KANESHIE ZONE MR2 245 329 283 857 %COY 80.04 107.49 92.46 93.33 Men A 245 329 283 857 %COY 80.04 107.49 92.46 93.33 Table 25, Abeka zone shows no differences in children expected to be vaccinated same day for MR2 and Men A but could not achieve the target of 95% and above. They vaccinated 1180 45 (85.68%) children but Kaneshie Polyclinic Static and Nii Boi CHPS was able to achieve the above set target of 95%. Table 175: Abeka Zone second year of life vaccination coverage for the first quarter of 2019. AREAS/ ZONES Indicators January February March First Quarter KPC STATIC MR2 99 75 52 226 %COY 129.41 98.04 67.97 98.47 Men A 99 75 52 226 %COY 129.41 98.04 67.97 98.47 ABEKACHPS MR2 87 76 87 250 %COY 71.12 62.13 71.12 68.12 Men A 87 76 87 250 %COY 71.12 62.13 71.12 68.12 FADAMACHPS MR2 115 135 0 250 %COY 100.15 117.56 0.00 72.57 Men A 115 135 0 250 %COY 100.15 117.56 0.00 72.57 NIIBOI CHPS MR2 256 198 0 454 %COY 176.05 136.16 0.00 104.07 Men A 256 198 0 454 %COY 176.05 136.16 0.00 104.07 ABEKAZONE MR2 557 484 139 1180 %COY 121.33 105.43 30.28 85.68 Men A 557 484 139 1180 %COY 121.33 105.43 30.28 85.68 Table 26, shows Achimota CHPS performance for the first quarter of 2019. All the areas performed below the set target which the zone vaccinated 311 (25 .41 % ) children for the three 46 month. Four areas did not report any child vaccinated for January and March namely Kissieman CHPS, Christian Village CHPS, Abofu CHPS and Anumle CHPS. Table 186: Achimota CHPS Zone second year of life vaccination coverage for the first quarter of 2019. AREAS/ ZONES Indicators January February March First Quarter AKWETEMAN CHPS MR2 92 80 0 172 %COY 144.31 125.49 0.00 89.93 Men A 92 80 0 172 %COY 144.31 125.49 0.00 89.93 ACH NS RD CHPS MR2 55 31 0 86 %COY 95.79 53.99 0.00 49.93 Men A · 55 31 0 86 %COY 95.79 53.99 0.00 49.93 KISSIEMAN CHPS MR2 0 17 0 17 %COY 0.00 88.70 0.00 88.70 Men A 0 17 0 17 %COY 0.00 88.70 0.00 88.70 X'VILLAGE CHPS MR2 0 16 0 16 %CO Y 0.00 83.48 0.00 83.48 Men A 0 16 0 16 %COY 0.00 83.48 0.00 83.48 ABOFU CHPS MR2 0 10 0 10 %COY 0.00 4.03 4.03 Men A 0 10 0 10 %COY 0.00 4.03 4.03 ANUMLECHPS MR2 0 10 0 10 %COY 0 Men A 0 10 0 10 %COY 0 ACHIMOTA CHPS MR2 147 164 0 311 %COY 36.04 40.20 0.00 25.41 Men A 147 164 0 311 %COY 36.04 40.20 0.00 25.41 47 Table 27, shows Tesano performance for the first three months of the year reveals serious action needed to be taken immediately to even achieve 85% coverage at the end year. Achimota Hospital Static was able to 100% and coverage but Tesano zone vaccinated 552 (13.74%) children. Table 197: Tesano Zone second year of life vaccination coverage for the first quarter of 2019. AREAS/ ZONES Indicators January February March First Quarter ACH HOSP STATIC MR2 175 121 0 296 %COY 274.51 189.80 0.00 154.77 Men A 175 121 0 296 %COY 274.51 189.80 0.00 154.77 APENKWA CHPS MR2 11 10 27 48 %COY 0 Men A 11 10 27 48 %COY 0 TESANO CHPS MR2 58 35 37 130 %COY 4.55 2.74 2.90 3.40 Men A 58 35 37 130 %COY 4.55 2.74 2.90 3.40 AYENORCHPS MR2 27 8 43 78 %COY 0 Men A 27 8 43 78 %COY 0 TESANOZONE MR2 271 174 107 552 %COY 20.24 13.00 7.99 13.74 Men A 271 174 107 552 %COY 20.24 13.00 7.99 13.74 48 4.2 Service Providers Factors Immunization activities all over the world use various strategies to get children vaccinated. Responses from respondents show various strategies, knowledge and practice used in the two zones in the second year of life vaccination. The following table below summarises the respective responses. 49 Table 208: Summary staff responses on questionnaires given them for the three months of data collection period April to June 2019. N(%) No Yes Know of 2nd Year of Life policy 51 (30.2) 118 (69.8) Know of 2nd Year of Life catch up policy 70 (41.4) 99 (58.6) Have 2nd Year of Life catch up policy 75 (44.4) 94 (55.6) Schedule clients for next visit 28 (16.6) 141 (83.4) Go for outreach 102 (60.4) 67 (39.6) Schedule clients for the second year of life vaccination after 111 (65.7) given 9 months vaccines 58 (34.3) Get to work or outreach point late 55 (32.5) 114 (67.5) Know Monthly Target Population 74 (43.8) 95 (56.2) Know Daily Target Population 142 (84.0) 27 (16.0) Analyse data daily 129 (76.3) 40 (23.7) Receive feedback from supervisors after submitting reports 117 (69.2) 52 (30.8) Have a shortage of Men A Vaccines 6 (3.6) 163 (96.4) Have a shortage of MR Vaccines 6 (3.6) 163 (96.4) Have an adequate sitting facility 102 (60.4) 67 (39.6) Give adequate information 102 (60.4) 67 (39.6) Vaccine administration done well 106 (62.7) 63 (37.3) Do tallies immediately 118 (69.8) 51 (30.2) Dispose of bottles appropriately 110(65.1) 59 (34.9) so Table 29: Interviewer observation during the administering of questionnaires on site. N % Child welfare clinic site Not adequate 99 58.6 Adequate 70 41.4 Cold chain observation Not good 43 25.4 Good 126 74.6 Staff Not enough 92 54.4 Enough 77 45.6 Strategy being used Static 54 32.0 Outreach 103 61.0 Mobile 12 7.1 Number of outreach points Good 66 39.1 Fair 84 49.7 Not good 19 11.2 Total 169 100.0 For each of the factors below in table 30, differences are shown by how immediate tallying is done. For example, for the 99 staff who said child welfare clinic sites that were inadequate, 26 (26.3%) of them carried out tallying immediately compared to 25 (35.7%) of the 70 child welfare clinics considered adequate. These differences were not significant though as shown from the p­ value (0.187). P-values below 0.05 are considered to show significant differences between categories been tested in relation to the outcome tallying. So in this case, significant differences in tallying are only seen for the number of outreach points and Schedule clients for the second 51 year of life vaccination after given 9 months vaccines. Fisher's exact test p-values are used in instances where frequencies are very low since they are more appropriate. Table 210: Relationship between staff adequacy, other factors and immediate tallying Tallying, N (%) Not Immediate Total Chi-square immediate P-value Child welfare clinic site 0.187 Not adequate 73 (73.7) 26 (26.3) 99 (100.0) Adequate 45 (64.3) 25 (35.7) 70 (100.0) Cold chain observation 0.447 Not good 32 (74.4) 11 (25.6) 43 (100.0) Good 86 (68.3) 40 (31.8) 126 (100.0) Staff 0.109 Not enough 69 (75.0) 23 (25.0) 92 (100.0) Enough 49 (63.6) 28 (36.4) 77 (100.0) Strategy being used 0.301 r Static 42 (77.8) 12 (22.2) 54 (100.0) Outreach 68 (66.0) 35 (34.0) 103 (100.0) Mobile 8 (66.7) 4 (33.3) 12 (100.0) Number of outreach points 0.009[ Good 51 (77.3) 15 (22.7) 66 (100.0) Fair 50 (59.5) 34 (40.5) 84 (I 00.0) Not good 17 (89.5) 2 (10.5) 19 (100.0) Schedule clients for the 0.003 second year of life vaccination after given 9 months vaccines No 69 (62.2) 42 (37.8) 111 (I 00.0) Yes 49 (84.5) 9 (15.5) 58 (I 00.0) Get to work or outreach point 0.053 late No 33 (60.0) 22 (40.0) 55 (100.0) Yes 85 (74.6) 29 (25.4) 114 (100.0) Total 118 (69.8) 51 (30.2) 169 (100.0) f: Fisher's exact p-value used instead due to some cell frequencies being low 52 Similar to the previous table, differences in terms of adequate information provided are shown for the same factors. In this case, significant differences are seen for Child welfare clinic site (p=0.003) and Staff (p=0.007). Table 221: Relationship between staff adequacy, other factors and provision of adequate information Adequate information, N(%) Not Chi-square Provided Total provided P-value Child welfare clinic site 0.003 Not adequate 69 (69.7) 30 (30.3) 99 (100.0) Adequate 33 (47.1) 37 (52.9) 70 (100.0) Cold chain observation 0.460 Not good 28 (65.1) 15 (34.9) 43 (100.0) Good 74 (58.7) 52 (41.3) 126 (100.0) Staff 0.007 Not enough 64 (69.6) 28 (30.4) 92 (100.0) Enough 38 (49.4) 39 (50.7) 77 (100.0) Strategy being used 0.200 Static 30 (55.6) 24 (44.4) 54 (100.0) Outreach 67 (65.1) 36 (34.9) 103 (100.0) Mobile 5 (41.7) 7 (58.3) 12 (100.0) Number of outreach points 0.450 Good 39 (59.1) 27 (40.9) 66 (100.0) Fair 49 (58.3) 35 (41.7) 84 (100.0) Not good 14 (73.7) 5 (26.3) 19 (100.0) Total 102 (60.4) 67 (39.6) 169 (100.0) 53 The responses that constituted output were put together to generate a composite score by giving the desired response a score of' l' and '0' if otherwise in table 32. The resulting total score was then converted to the percentage scale. So for example, respondents that had 'Good' cold chain observations had an average Output score of 49.4%, a bit higher than those without good cold chain observation who had an output score of 4 7 .2%. Table 232: Differences in some observations Mean SD Child welfare clinic site Not adequate 42.9 13.0 Adequate 57.3 20.4 Cold chain observation Not good 47.2 16.5 Good 49.4 18.3 Staff Not enough 44.8 12.4 Enough 53.8 21.8 Strategy being used Static 53.9 20.7 Outreach 43.4 12.0 Mobile 73.3 20.6 Number of outreach points Good 53.9 19.3 Fair 44.6 14.8 Not good 50.0 21.3 Total 48.9 17.9 The mean differences in output levels between facilities in terms of shortage of Men A and MR vaccines are shown below in Table 33. The same facilities which could be CHPS compound or 54 outreach points that had a shortage of Men A also had the shortage of MR vaccines and so the same results can be used for both vaccine types. The facilities without shortage had a mean output level of 23.3% compared to the mean output level of 49.8% for those with shortage and this difference was highly significant (p<0.001). Table 243: Differences in output levels and shortage of Men A and MR vaccines Wilcoxon No. S.E. S.D. Mean 95% C.I. for Mean Rank Sum Vaccines No shortage 6 2.11 5.16 23.3 17.9 28.8 z = -4.06 Had shortage 163 1.37 17.48 49.8 47.1 52.5 p<0.001 Combined 169 1.38 17.88 48.9 46.2 51.6 Difference 2.51 -26.48 -32.08 -20.89 Fisher ' s exact test p-values were used to compare if significant difference exists in terms of shortages of the vaccines for facilities that know or did not know 2nd Year of Life (and catch up) policies in table 34. All facilities that know the policies also had a shortage of the vaccines compared to only some of those that didn't know the policies and these differences were significant as seen from the p-values . Fisher's exact test p-values are used due to the Jow frequencies in some cells. But care must be taken in explaining this so it does not seem as if it is the absence of knowledge of the policies that are entirely to blame for the shortages. The same facilities had a shortage of Men A and MR vaccines and so the same results can be used in both cases. 55 Table 254: Differences in output and input (vaccine shortages and 2nd Year of Life policy) Men A/MR vaccine Fisher's No Had Total exact shortage shortage P-value 2nd Year of Life policy <0.001 Didn't Know 6 (11.8) 45 (88.2) 51 (100.0) Did Know 0 118 (100.0) 118 (100.0) 2nd Year of Life catch up policy 0.007 Didn't Know 6 (8.0) 69 (92.0) 75 (100.0 ) Did Know 0 94 (100.0) 94 (100.0) Total 6 (3.6) 163 (96.5) 56 4.3 Health facility factors 4.3.1 Vaccine availability and adequacy Vaccine levels found at Kaneshie Polyclinic are shown below. 3500 3000 2500 2 iJ 2000 I.I.. O 1500 V'I w V'I g 1000 500 0 I I II I II I Beginning Stock Received Issues II Ending Stock Source : Kaneshie polyclinic vaccine ledger books at Disease Control Unit. I Figure 5: Monthly availability of Conjugate A Meningococcal vaccines in Okaikoi Sub metro for 2017. Figure 5, shows how Kaneshie Polyclinic receive and serves vaccines as the Submetro cold room from where all facilities collect their vaccine requirements. The annual stock level expected was 19643 and they achieved 19290, expected monthly stock level 1637 with an expected minimum stock level of 409 and maximum stock level 2046 . Average monthly consumption was 1607.5 indicating adequate monthly availability. The beginning stock reveals quite a shortage of vaccine before restocking for four months from September to December. 57 2500 2000 V'I w z 0 1500 u u.. 0 V'I 1000 w V'I 0 C 500 0 I. I I Beginning Stock Received Issue Ending Stock January February March April Source : Kaneshie polyclinic vaccine ledger books at Disease Control Unit. Figure 7: Monthly availability of Conjugate A Meningococcal vaccines in Okaikoi Sub metro for the first four months in 2019. The average monthly consumption was 1592.5 indicating adequate monthly availability for the four months in 2019. The beginning stock reveals delay in restocking of vaccines especially in March which resulted in quite shortage. The annual stock level expected was 40664 and they achieved 6370, expected monthly stock level 3389 with an expected minimum stock level of 847 and maximum stock level 4236 . 59 V, U.J 4500 4000 3500 3000 u 2500 I.I. O 2000 V, U.J 0 1500 C 1000 500 0 I I I I I Beginning Stock Received I I I Issues Ending Stock Source: Kaneshie polyclinic vaccine ledger books at Disease Control Unit. II Figure 8: Monthly availabili ty of Measles-Rubella vaccines in Okaikoi Sub metro for 2017. Kaneshie Polyclinic serves as the Submetro cold room from where all faciliti es collect their Measles-Rubella vaccine requirements. The annual stock level expected was 39286 and they achieved 28130 , expected monthly stock level 3274 with an expected minimum stock level of 818 and maximum stock level 4092 . Average monthly consumption was 2344.2 indicating adequate monthly availability. 60 V) LU 6000 5000 4000 u u <( 3000 0 V) LU 0 2000 0 1000 0 I I Beginning Stock Received Issues I I Ending Stock Source: Kaneshie polyclinic vaccine ledger books at Disease Control Unit. Figure 9: Monthly availabil ity of Measles-Rubella vaccines in Okaikoi Sub metro for 2018. The average monthly consumption was 1912.5 indicating adequate monthly availability. The beginning stock reveals a shortage of vaccine for some days before restocking. The annual stock level expected was 40281 and they achieved 22950, expected monthly stock level 3357 with an expected minimum stock level of 839 and maximum stock level 4196. 61 4000 3500 3000 V') w z 2500 u u 2000 u. a V') w 1500 V') a Cl 1000 500 0 Beginning Stock Received Issues Ending Stock . January February March April Source: Kaneshie polyclinic vaccine ledger books at Disease Control Unit. Figure 10: Monthly availab ility of Measles-Rubella vaccines in Okaikoi Sub metro for first four months in 2019. The average monthly consumption was 2180 indicating adequate monthly availability for the four months in 2019 . The beginning stock reveals delay in restocking of vaccines especially in March which resulted in quite a shortage. The annual stock level expected was 40281 and they achieved 8720, expected monthly stock level 3357 with an expected minimum stock level of 839 and maximum stock level 4236. 62 V) w 2 3000 2500 u 2000 u 0 1500 V) w 0 1000 0 500 0 I I I I 11 I 2017 2018 2019 Figure 11: Shows Conjuga te A Meningococcal vaccines in Okaikoi Sub metro for various months in 2017, 2018 and the first four months of 2019. 63 3500 3000 V) 2500 LU z 0 2000 u u.. 1500 0 V) LU V) 1000 0 0 500 0 I 2017 2018 2019 Figure 12: Shows Measles- ubella vaccines in Okaikoi Sub metro for various months in 2017, 2018 and the first four months of 2019. Figure 11 and 12 show vaccines distributed from Kaneshie polyclinic to facilities . The distribution in 2017 is higher than in 2018 by 35.87% for Men A and 18.42% for MR yet there was a shortage in 2017. The shortage is due to late receiving of stock within the month but not for the entire month. The first four months of 2019 stock level has seen some significant improvement over the previous years by 5.39% same time. 64 3500 C UJ 3000 z u 2500 > 2000 0::: C _, J: 1500 u u. 0 1000 II 0::: UJ I C0 2 500 ::) z 0 11 I II I I 11 I I I Vaccines Issued Children Vaccinated Figure 13: shows Okaikoi Submetro Conjugate A Meningococcal vaccines issued as compared with the children vaccinated for 2017. 65 2000 C w 1800 !:i Z 1600 0 u 1400 z 1200 UJ 0:: C 1000 ....I 0 800 IL. 0 600 0:: 400 => 200 z 0 Vaccines Issued Children Vaccinated Figure 14: Differences in Okaikoi Submetro Conjugate A Meningococcal vaccines issued