Evaluation of Health Facility Performance in Childhood Immunization Services in Selected Facilities of Sikongo District in the Western Province of Zambia

Abstract

Despite the fact that immunization is an essential component of all countries, there are still gaps in terms of coverage, timeliness and equity in several parts of those countries, especially in low resource settings. The primary aim of this dissertation was to identify the gaps within the immunization programs of Sikongo District in the Western Province of Zambia by assessing various aspects of the immunization records of children within health facilities in the district. A retrospective cross-sectional study was performed using the child health registers and under 5 cards in five health facilities. Each document was scored for its quality according to the completeness of the documents, availability of the documents, legibility of the documents and accuracy of the information within those documents to create a document quality index (DQI). Based on Zambia’s EPI cycle vaccine specific coverage, the percentage of children who drop out between doses of the vaccines was calculated, as was the percentage who received each of the three types of doses (early, on time, and late). Tests that did not assume anything about the distribution of variables within the sampling areas were used to compare the facility-level comparisons. Such as the Pearson’s chi-square test. Additionally, logistic regression was used to determine which variables were associated with the likelihood that a child would be late in receiving the complete immunization series or would be fully immunized. The indicator pathway that linked vaccination documentation to vaccination itself and timeliness in receiving the vaccines was calculated using linear mixed modelling techniques. Spatial autocorrelation analyses (both global and local Moran’s I statistics) were used to determine which geographic areas within the selected catchment areas of Sikongo District in the Western province of Zambia had high vaccine coverage for several antigens and which had lower rates, including any villages that exhibited “cold spots” in relation to vaccination. The documentation quality index (DQI) for all primary vaccination records was generally high; 80.6% of documentation records had high DQI scores and low instances of missing variables or missing data. Furthermore, vaccination quality was significantly associated with full immunization (95% of the children who were fully immunized had documentation records that reflected high DQI scores). However, this association requires cautious interpretation as both measures were derived from the same documentation. Coverage exceeded 95% for DTP1–3 and IPV with minimal dropout between intermediate doses. Higher dropouts were observed between BCG and OPV0 as well as between IPV and MR1(4.6% and 6.6% respectively). The timeliness of these vaccines was lower than the coverage. While birth doses were generally administered in time with more than 80% of BCG and OPV0 doses administered within the recommended timeliness window, timeliness declined for later doses, with only around one third of DTP3 and IPV doses administered within the recommended age window. Overall, 53.4% of children had at least one late dose. Nyengo and Tuuwa had the highest mean vaccine coverage among the five selected facilities. Mwenyi had the lowest. Spatial analysis identified areas with clustering of fully immunized children and villages with few fully immunized children. Children who lived further from the clinics, who missed more clinic appointments, and who were classified as “defaulter” children had higher odds of being late or not being fully immunized. Higher documentation quality is associated with lower odds of late or incomplete immunization. This relationship is to be interpreted cautiously as the documentation quality and vaccination outcomes were derived from the same routine records. The sex of the child was not associated with the outcomes, as was the number of health workers at the clinics or the number who performed health outreach within the clinics. The five clinics had high vaccine coverage for several antigens and documentation of those vaccinations. However, there were gaps in the rates of success with providing birth doses and MR1 vaccines to the children, and the timeliness with which they received those vaccines. Greater distance to the health facility was associated with poorer immunization outcomes. Most underperforming facilities were in Mwenyi. for the clinics include the administration of catch-up vaccines for MR1 vaccines, strengthening immunization programmes within underperforming clinics, improving the provision of birth doses (especially to Nyengo clinic), improving appointment management and defaulter management within clinics, and performing health outreach to the specific villages with identified gaps in providing vaccines to their populations. Additionally, timeliness within clinics should be more closely monitored, and documentation processes should be strengthened, standardised and streamlined across facilities.