Success in vaccination programming through community health workers: a qualitative analysis of interviews and focus group discussions from Nepal, Senegal and Zambia.

OBJECTIVES: Community health workers are essential to front-line health outreach throughout low-income and middle-income countries, including programming for early childhood immunisation. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunisation coverage would support evidence-based policy guidance across contexts. DESIGN: We employed a multiple case study design using qualitative research methods. SETTING: We conducted research in Nepal, Senegal and Zambia. PARTICIPANTS: We conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility and community levels of the health systems of Nepal, Senegal and Zambia, from October 2019 to April 2021. We used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunisation within each country and across contexts. RESULTS: Implementation of vaccination programming relied principally on the (1) organisation, (2) motivation and (3) trust of community health workers. Organisation was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on their work. CONCLUSION: Improvements in immunisation coverage was facilitated by community health worker organisation, motivation and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to underserved populations. Although improvements in vaccination programming were seen in all three countries-including government commitment to addressing human resource deficits, training and remuneration; workload, inconsistency in compensation, training duration and scope, and supervision remain major challenges to immunisation programming. Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming.

Factors associated with vaccine coverage improvements in Senegal between 2005 and 2019: a quantitative retrospective analysis.

OBJECTIVE: Senegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared with other low-income and lower-middle income countries. Understanding factors associated with historical changes in childhood vaccine coverage in Senegal, as well as heterogeneities across its 14 regions, can highlight effective practices that might be adapted to improve vaccine coverage elsewhere. DESIGN: Childhood vaccination coverage rates, demographic information and health system characteristics were identified from Senegal's Demographic and Health Surveys (DHS) and Senegal national reports for years 2005-2019. Multivariate logistic and linear regression analyses were performed to determine statistical associations of demographic and health system characteristics with respect to childhood vaccination coverage rates. SETTING: The 14 administrative regions of Senegal were chosen for analysis. PARTICIPANTS: DHS women's survey respondents with living children aged 12-23 months for survey years 2005-2019. OUTCOME MEASURES: Immunisation with the third dose of the diphtheria-tetanus-pertussis vaccine (DTP3), widely used as a proxy for estimating immunisation coverage levels and the retention of children in the vaccine programme. RESULTS: Factors associated with childhood vaccination coverage include urban residence (ß=0.61, p=0.0157), female literacy (ß=1.11, p=0.0007), skilled prenatal care (ß=1.80, p<0.0001) and self-reported ease of access to care when sick, considering travel distance to a healthcare facility (ß=-0.70, p=0.0009) and concerns over travelling alone (ß=-1.08, p<0.0001). Higher coverage with less variability over time was reported in urban areas near the capital and the coast (p=0.076), with increased coverage in recent years in more rural and landlocked areas. CONCLUSIONS: Childhood vaccination was more likely among children whose mothers had higher literacy, received skilled prenatal care and had perceived ease of access to care when sick. Overall, vaccination coverage is high in Senegal and disparities in coverage between regions have decreased significantly in recent years.

A small area model to assess temporal trends and sub-national disparities in healthcare quality.

Monitoring subnational healthcare quality is important for identifying and addressing geographic inequities. Yet, health facility surveys are rarely powered to support the generation of estimates at more local levels. With this study, we propose an analytical approach for estimating both temporal and subnational patterns of healthcare quality indicators from health facility survey data. This method uses random effects to account for differences between survey instruments; space-time processes to leverage correlations in space and time; and covariates to incorporate auxiliary information. We applied this method for three countries in which at least four health facility surveys had been conducted since 1999 - Kenya, Senegal, and Tanzania - and estimated measures of sick-child care quality per WHO Service Availability and Readiness Assessment (SARA) guidelines at programmatic subnational level, between 1999 and 2020. Model performance metrics indicated good out-of-sample predictive validity, illustrating the potential utility of geospatial statistical models for health facility data. This method offers a way to jointly estimate indicators of healthcare quality over space and time, which could then provide insights to decision-makers and health service program managers.

Determinants of complete immunization among senegalese children aged 12-23 months: evidence from the demographic and health survey.

BACKGROUND: The expanded Programme on Immunization (EPI) is one of the most cost-effective interventions to reduce childhood mortality and morbidity. However, determinants of childhood immunization have not been well studied in Senegal. Thus, the aim of our study is to assess routine immunization uptake and factors associated with full immunization status among Senegalese children aged 12-23 months. METHODS: We used the 2010-2011 Senegalese Demographic and Health Survey data. The DHS was a two stages cross-sectional survey carried out in 2010-2011. The analysis included 2199 children aged 12-23 months. The interviewers collected information on vaccine uptake based on information from vaccination cards or maternal recall Univariate and multivariable logistic regressions models were used to identify the determinants of full childhood immunization. RESULTS: The prevalence of complete immunization coverage among boys and girls based on both vaccination card information and mothers' recall was 62.8%. The immunization coverage as documented on vaccination cards was 37.5%. Specific coverage for the single dose of BCG at birth, the third dose of polio vaccine, the third dose of pentavalent vaccine and the first dose of measles vaccine were 94.7%, 72.7%, 82.6%, and 82.1%, respectively. We found that mothers who could show a vaccination card [AOR 7.27 95% CI (5.50-9.60)], attended at least secondary education level [AOR 1.8 95% CI (1.20-2.48)], attended four antenatal visits [AOR 3.10 95% CI (1.69-5.63)], or delivered at a health facility [AOR 1.27 95% CI (1-1.74)] were the predictors of full childhood immunization. Additionally, children living in the eastern administrative regions of the country were less likely to be fully vaccinated [AOR 0.62 95% CI (0.39-0.97)]. CONCLUSIONS: We found that the full immunization coverage among children aged between 12 and 23 months was below the national (> 80%) and international targets (90%). Geographic area, mother's characteristics, antenatal care and access to health care services were associated with full immunization. These findings highlight the need for innovative strategies based on a holistic approach to overcome the barriers to childhood immunization in Senegal.