Embedding implementation research to strengthen efforts towards improving primary health care in resource limited settings

Immunization reaches more people than any other health service and it is a vital component of primary health care (PHC) (1,2). The Immunization Agenda 2030 emphasizes building strong national immunization programs integrated into primary health care services as the basis for achieving high vaccination coverage (2). In Ethiopia, immunization services are the backbone of PHC and are delivered in all public health facilities across the country (1). Even though the national EPI target is to reach a coverage of 90%(1), achieving and maintaining high immunization coverage is challenged by multifaceted demand and supply side implementation barriers (3–5). These barriers are related to community engagement, immunization service delivery, supply chain management, and surveillance and data management of the immunization program (5). Consequently, the national full vaccination coverage stalled at 43% (6)

Immunization data quality and factors influencing data generation, handling and use in Wogera District, Northern Ethiopia, 2020

Abstract Background: Data quality is a vital metric in health information systems to ascertain improved health of individuals and community as well. Immunization data are critical inputs in assessing national performance of expanded program on immunization and child health improvement. Inconsistent health data happens when variations arise in the report and re-count from the source documents. Aim: This study aimed to assess immunization data quality and factors influencing data generation, handling, and use. Methods: Both qualitative and quantitative data were used. Immunization recording and reporting documents were reviewed at 41 health facilities of primary health care units. Twenty health workforces were interviewed on healthcare data quality, generation, handling, and use. The Statistical Package for the Social Sciences (SPSS) for windows version 26 was used to perform quantitative data analysis and open code version 4.02 was used for qualitative data analysis. Data accuracy was presented using mean and standard deviation of data verification factor. Results: Over-reporting of immunization data elements was observed. The highest accuracy (75%) was reported for full immunization at health center level followed by 62.5% for measles. The difference between verification factor of ideal reports and observed values, indicates that there is over reporting in all immunization data elements by 44% (27-61%), 46% (=31-61%), 40% (12-61%), 37% (11-63%), and 38% (12-64%) in BCG, Penta 1, Penta 3, measles, and full immunization, respectively. Supervision, availability of recording and reporting tools, training, motivation, attitudes towards healthcare data, hard to reach areas and manual documentation were influencing factors of immunization data quality, generation, handling, and use. Conclusion: The study revealed that health facilities over-reported immunization data elements in primary health care units. Attentions should be given to address organization, behavioral, technical, and contextual factors influencing immunization data quality, generation, handling, and use. [Ethiop. J. Health Dev. 2021; 35(SI-3):56-64] Keywords: Immunization data quality, Factors influencing, Verification factor, Wogera distric

Existing models of maternal death surveillance systems : protocol for a scoping review

Background: Maternal mortality measurement remains a critical challenge, particularly in low and middle income countries (LMICs) where little or no data are available and maternal mortality and morbidity are often the highest in the world. Despite the progress made in data collection, underreporting and translating the results into action are two major challenges that maternal death surveillance systems (MDSSs) face in LMICs. Objective: This paper presents a protocol for a scoping review aimed at synthesizing the existing models of MDSSs and factors that influence their completeness and usefulness. Methods: The methodology for scoping reviews from the Joanna Briggs Institute was used as a guide for developing this protocol. A comprehensive literature search will be conducted across relevant electronic databases. We will include all articles that describe MDSSs or assess their completeness or usefulness. At least two reviewers will independently screen all articles, and discrepancies will be resolved through discussion. The same process will be used to extract data from studies fulfilling the eligibility criteria. Data analysis will involve quantitative and qualitative methods. Results: Currently, the abstracts screening is under way and the first results are expected to be publicly available by mid-2017. The synthesis of the reviewed materials will be presented in tabular form completed by a narrative description. The results will be classified in main conceptual categories that will be obtained during the results extraction. Conclusions: We anticipate that the results will provide a broad overview of MDSSs and describe factors related to their completeness and usefulness. The results will allow us to identify research gaps concerning the barriers and facilitating factors facing MDSSs. Results will be disseminated through publication in a peer-reviewed journal and conferences as well as domestic and international agencies in charge of implementing MDSS

The Implementation of Social and Behavior Change Communication Intervention to Improve Immunization Demand: A qualitative study in Awabel District, Northwest Ethiopia

AbstractBackground: Immunization coverage in Ethiopia is low, and dropout rates are high. Social Behavior Change Communication (SBCC) interventions were introduced as a means of combating the ‘demand-side’ immunization barriers. However, Little research exists in terms of the efficacy of the SBCC intervention, in terms of promoting uptake, and improving the immunization demands in Ethiopia.Aim: To explore the current implementation status, and perceived effectiveness of SBCC intervention, barriers and facilitators with new strategies aimed at effective implementation of the SBCC intervention in Awabel District, Northwest Ethiopia.Methods: A phenomenological qualitative study was conducted from January 1- October 31, 2020. In-dept interviews were conducted with fifteen key-informants using a piloted semi-structured interview guide. Participants were purposively selected, which comprised of mangers, Expanded Program of Immunization (EPI) focal personnel, Health Extension Workers (HEWs), Women Development Armies (WDAs), mothers and community representatives. Six vaccination sessions were observed. Coding was done to identify patterns. Thematic analysis was performed using Open Code 4. 02.Results: Interpersonal communication, community conversation, social mobilization and family modeling were used as SBCC approaches. HEWs were the key source of information. Religious leaders were among the major stakeholders that encourage immunization. SBCC was perceived as an effective measure to improve immunization demand. There were multiple barriers for implementation of SBCC interventions including limited resources, lack of awareness, geographic barriers, traditional beliefs, lack of incentives, and limited EPI staff and health facility operating hours. Engagement of fathers and religious leaders, strengthening the WDA, and allocation of more resources were listed as possible strategies to tackle barriers.Conclusion: The implementation of SBCC interventions is important to improve immunization demand. Despite its effectiveness, there are several multi-level barriers to its successful implementation. Further, greater investments are required to improve infrastructures, staff employment and capacity building. [Ethiop. J. Health Dev. 2021; 35(SI-3):49-55]Keywords: Immunization, SBCC, Ethiopi

How to optimize Immunization Supply Management at different levels of the health system in Oromia Region? An implementation science research

AbstractBackground: In programs like immunization having strong supply management is important to benefit all the necessary inputs of the health system. In Ethiopia, it has been found, that vaccine availability at service delivery points is low. Moreover, the implementation barriers related to Immunization Supply Management are vague at each level of the health system.Aim: This study aimed to explore the practice, barriers and alternative strategies related to immunization supply management in the Oromia region, west Ethiopia.Methods: A phenomenological qualitative approach was used. The data was collected using interview guides among 27 key informants from health posts, health centers, woreda health office, regional hub and Ethiopian Pharmaceutical supply Agency from June 15 to July 10, 2020. All the audio data were independently transcribed verbatim from Amharic and Afaan Oromo languages after repeatedly listening to the records and then translated into the English. The translated transcription documents were imported into Open Code software 4.02 for the purpose of coding. The coding was performed by three experts independently. Thematic analysis was utilized for the analysis of the data.Results: The immunization supply management practices were categorized into three themes: Vaccine forecast, vaccine request & delivery and stock management of vaccines. Organizational (lack of reviewing processes, lack of transportation, lack of refrigerators, interrupted power supply, absence of vaccine forecasting team, unavailability of performance evaluation reports and lack of electricity), technical (lack of standard leger book and lack of vaccine requisition form) and behavioral (lack of accountability, skill gaps and negligence) barriers were the main determinants that affect vaccine availability. The alternative strategies to optimize the ISM include local data-based forecasting, direct delivery of the vaccine to health facilities, transforming the ISM through digitalization and to establish accountability.Conclusion: This study showed that the existing immunization supply management practice is not optimal. Organizational, technical, and behavioral barriers were the identified determinants for low availability. Therefore, program managers and policymakers should emphasize addressing the identified barriers and tailoring the alternative strategies to ensure the availability of vaccines at the point of service delivery. [Ethiop. J. Health Dev. 2021; 35(SI-3):65-74]Keywords: Immunization, Implementation research, Supply Management, Health system, Ethiopi

How to optimize health facilities and community linkage in order to enhance immunization service? The case of West Amhara Region, Ethiopia

AbstractBackground: Health facility-community linkages are important in designing community-level interventions, appropriate immunization service provision modalities, and changing unhealthy behaviors. However, there is limited evidence on the influence of community and facility linkage on vaccination services in Ethiopia.Aim: This study aimed to explore how the linkage between health facilitiesa and the community could be optimized in order to enhance immunization services.Methods: A Phenomenological study design, using an explanatory approach was applied in the two districts (Shebele Berenta & South Achefer district) of the Amhara region for the month of June , 2020. Forty-six key informants were interviewed using an interview guide and data was analyzed using open code version 4.02. The data was coded, and thematic analysis was applied.Results: The finding revealed that there were community platforms to facilitate community and health facility linkage. Respondents also perceived that the community to health facility linkage was an effective strategy for the Expanded Program on Immunization (EPI) service provision. The study revealed that perception of health care providers, health care providers attitude and practices, shortages of stock (medication and supplies), distance from main road and transportation, irregularity in the implementation of rules and regulations, lack of incentives, inadequate counseling and support, lack of awareness, shortages of human resources and lack of training support for health care workers were barriers for effective community-health facility linkage.Conclusion: The linkage of community and facilities were not approached in the same manner within districts and facilities. Therefore, strengthening a common system for community-health facility linkage and community engagement is critical during immunization services. Establishing a strong strategy of incentivizing mechanisms is vital for the effective implementation of immunization services. An advocacy strategy to mobilize engagement among policy and decision-makers, and other key stakeholders was an important strategy for improving the program. [Ethiop. J. Health Dev. 2021; 35(SI-3):75-85]Keywords: Community, Facility linkage, EPI, Amhara Region, Ethiopi

Assessment of immunization data management practices, facilitators, and barriers to immunization data quality in the health facilities of Tach Gayint district, Northwest Ethiopia

AbstractIntroduction: Although data quality mainly depends upon the proper management of its primary sources, limited studies examined immunization data management practice in Ethiopia.Aim: To explore data management practices, facilitators, and barriers to immunization data quality among front-line immunization experts in the Tach Gayint district of Northwest Ethiopia.Methods: A mixed method study design was applied using document review and key-informant interviews. Quantitative data was collected through document review from 18 health facilities and 26 key-informant interviews, were conducted on experts of immunization for qualitative data. A STATA version 14.1 was used for quantitative data analysis. Qualitative data was transcribed verbatim and translated back into English. Data was coded, reduced, and searched for salient patterns. Thematic analysis was done using open-code version 4.02.Results: The Health Management Information System data recording tools were often lacking. The significant number (83.3%) of health facilities practiced immunization information display, while dissemination at the local level was low. The key informants mentioned that they were responsible for conducting regular Performance Monitoring Team (PMT) and Lots Quality Assurance Sampling (LQAS) as facilitators. Furthermore, a shortage of recording tools, limited supportive supervision, vertical reporting, impracticality of Lots of Quality Assurance Sampling (LQAS) at the health posts, poor implementation of Community Health Information System (CHIS), and mass vaccination were barriers identified to immunization data quality.Conclusion: We found that majority of health workers use locally developed tools instead of using the standard data recording and reporting tools. Regular Performance Monitoring Team meetings and Lots Quality Assurance Sampling assessment were found to be facilitators. Furthermore, limited supportive supervision, vertical reporting and poor implementation of Community Health Information System were barriers. Therefore, strengthening the use of standard recording and reporting tools, conducting regular supportive supervision, and implementing routine vaccination services are recommended to improve the data management practice. [Ethiop. J. Health Dev. 2021; 35(SI-3):28-38]Key words: Immunization, Data management practice, Data quality, Information us

Maternal and Child Health Services in the Context of the Ebola Virus Disease: Health Care Workers’ Knowledge, Attitudes and Practices in Rural Guinea

The objective of this study was to document maternal and child health care workers‘ knowledge, attitudes and practices on service delivery before, during and after the 2014 EVD outbreak in rural Guinea. We conducted a descriptive cross-sectional study in ten health districts between October and December 2015, using a standardized self-administered questionnaire. Overall 299 CHWs (94% response rate) participated in the study, including nurses/health technicians (49%), midwives (23%), managers (16%) and physicians (12%). Prior to the EVD outbreak, 87% of CHWs directly engaged in managing febrile cases within the facility, while the majority (89% and 63%) referred such cases to another facility and/or EVD treatment centre during and after the EVD outbreak, respectively. Compared to the period before the EVD outbreak when approximately half of CHWs (49%) reported systematically measuring body temperature prior to providing any care to patients, most CHWs reported doing so during (98%) and after the EVD outbreak (88%). The main challenges encountered were the lack of capacity to screen for EVD cases within the facility (39%) and the lack of relevant equipment (10%). The majority (91%) of HCWs reported a decrease in the use of services during the EVD outbreak while an increase was reported by 72% of respondents in the period following the EVD outbreak. Infection prevention and control measures established during the EVD outbreak have substantially improved self-reported provider practices for maternal and child health services in rural Guinea. However, more efforts are needed to maintain and sustain the gain achieved.Key words: Maternal and child health, practices, Ebola, Guine

Closing the know-do gap for child health: UNICEF's experiences from embedding implementation research in child health and nutrition programming.

UNICEF operates in 190 countries and territories, where it advocates for the protection of children's rights and helps meet children's basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.This paper presents UNICEF's embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale

An embedded implementation research initiative to tackle service delivery bottlenecks in the expanded programme on immunisation in Pakistan: Overview and reflections.

BACKGROUND: Embedded implementation research (IR) can play a critical role in health systems strengthening by tackling systems and implementation bottlenecks of a program. To achieve this aim, with the financial support of GAVI, the Vaccine Alliance, in 2016, the Government of Pakistan, UNICEF and the Alliance for Health Policy and Systems Research (AHPSR) launched an Embedded IR for Immunisation Initiative (the Initiative) to explore health systems and implementation bottlenecks, and potential strategies to tackle such bottlenecks in the Expanded Programme on Immunisation (EPI) in Pakistan. In total, 10 research teams were involved in the Initiative, which was the first of its kind in the country. In this paper, we provided a brief overview of the Initiative's approach as well as the key learnings including challenges and successes of the research teams which could inform future embedded IR Initiatives. METHODS: Data were collected from members of the IR teams through an online survey. In addition, in-depth interviews were conducted via phone and in-person from IR team members to explore further the challenges they faced while conducting IR in Pakistan and recommendations for future IR initiatives. The qualitative information obtained from these sources was collated and categorized into themes reflecting some of the challenges, successes, and lessons learned, as well as teams' recommendations for future initiatives. RESULTS: The embedded IR Initiative in Pakistan followed several steps starting with a desk review to compile information on key implementation challenges of EPI and ended with a dissemination workshop where all the research teams shared their IR results with policymakers and implementers. Key factors that facilitated the successful and timely completion of the studies included appreciation by and leadership of implementers in generation and use of local knowledge, identification of research priorities jointly by EPI managers and researchers and provision of continuous and high-quality support from in-country research partners. Participants in the Initiative indicated that challenges included a lack of clarity on the role and responsibilities of each partner involved and need for further support to facilitate use and dissemination of research findings. CONCLUSIONS: The Initiative established that an immunisation programme in a lower middle-income country can use small and time-bound embedded IR, based on partnerships between programme managers and local researchers, to generate information and evidence that can inform decision-making. Future embedded IR initiatives should strive to ensure effective coordination and active participation of all key stakeholders, a clear research utilisation plan from the outset, and efforts to strengthen research teams' capacity to foster utilisation of research findings