Coverage and use of insecticide-treated bed nets in households with children aged under five years in Liberia.

SETTING: St John's District, Grand Bassa County, Liberia. OBJECTIVES: In households with children aged <5 years, to examine the coverage and use of long-lasting insecticide-treated bed nets (LLINs), factors associated with non-use and the characteristics and conditions of bed nets. DESIGN: Cross-sectional study involving interviews with mothers and visual inspection of LLINs. RESULTS: Of 663 households visited, 492 (74%) had no LLIN and 135 (20%) had one LLIN. Of 171 households with LLINs, these were consistently used by 73 (43%) children. The main reasons for inconsistent use included LLINs being old or damaged, and LLINs generating too much heat for 20-30% of children. Visual inspection of LLINs in 130 households showed that 98% of LLINs were white, 20% were not hung above the child's sleeping place, 30% had holes, 84% were double-bed sized and 82% had been washed in the previous 6 months. CONCLUSION: Despite reports of 100% LLIN coverage in St John's District, this study showed that only a quarter of households had an LLIN, over half of the children used LLINs inconsistently and the LLINs had several deficiencies. More surveys should be conducted to determine the true coverage of LLINs in Liberia, and measures must be taken to improve the use of LLINs.

Reaching every district (RED) approach to strengthen routine immunization services: evaluation in the African region, 2005.

BACKGROUND: This evaluation was undertaken in 2005, in the African region, to better understand the reaching every district (RED) implementation process that provides a framework for strengthening immunization services at the district level. METHODS: In June 2005, a convenience sample of five countries was selected to evaluate the implementation of RED. Evaluation teams consisting of key partners conducted site visits to the national, district and health facility levels using standardized qualitative questionnaires. RESULTS: RED was implemented in a similar manner in all five countries, i.e. starting with training and micro-planning. All RED components were implemented to some degree in the countries. Common implementation factors included development of plans, expanding outreach services (defined as services provided in sites outside fixed immunization sites), planning of supervisory visits and efforts to link with communities and utilize community volunteers. Monitoring tools such as wall charts and maps were observed and reportedly used. CONCLUSIONS: Evaluation of the RED implementation process provided evidence of improvement in delivery of routine immunization services. The RED framework should continue to be used to strengthen the immunization delivery system to meet continuing new demands, such as the introduction of new vaccines and integrated delivery of other child survival interventions.

How disease prevention fails without good communication.

Even where resources are plentiful, efforts to achieve full immunization coverage fail if staff and users are misinformed and unmotivated. A highly practical study in Lagos pinpoints some of these failures and suggests ways of overcoming them.

PIP: After a preliminary assessment in 1991 showed that immunization services in Lagos were among the worst in Nigeria, Resources for Child Health (REACH) started a multi-component demonstration project in the city. The communications component consisted of focus groups with users and interviews with providers to determine beliefs and practices in order to assess the support for the immunization service and discover ways of strengthening it. Based on data from the 1991 survey, questions were designed to discover why opportunities for immunization were missed and why health workers were giving mothers misinformation. The 15 focus groups consisted of 15 people each (3 with fully immunized children) from each socioeconomic group. The interviews were conducted in the same 4 localities as the focus groups with 11 physicians, 25 nurses, and 12 community health workers. In the focus groups, users blamed incomplete immunization on attributes of the health services and on factors which they themselves controlled. The former included negative staff attitudes, long waiting times, missed opportunities (including refusal to immunize even mildly sick children), and reduced potential contact hours. The latter included fear of side effects, lack of motivation, misinformation, pressures of work, and the laziness or carelessness of the mother (in the view of fathers). The nurses and health workers blamed lack of coverage on the mothers working or traveling, ignorance or carelessness on the part of the mothers, illness in the children, side effects, a preference for native methods, and staff attitudes. It was found that 84% of the nurses and 81.8% of the health workers provided completely accurate counseling information. After analyzing the suggestions of the health workers for improving services and the perception of the physicians about areas in which staff training could improve, REACH recommended that possible contact hours between the mother and the health services be increased, that staff attitudes be improved, and that the knowledge of health workers be updated and improved. Each immunization district in Lagos State now has its own plan to implement these recommendations.

Improving vaccination completion rates in liberia: evaluation of an intervention trial.

Reported are findings from an evaluation of a community-based strategy employing local chiefs and traditional midwives as extenders of the Ministry vaccination team for the purpose of increasing vaccination completion in Liberia, West Africa. The intervention strategy-a training workshop and two subsequent supervisory visits-was selected from among those generated in Stage 1 of a three-stage operational research design. Evaluation of the intervention was carried out after an eight-month follow-up period. Visits to intervention and control villages, for the purpose of interviewing chiefs, traditional midwives (TMs) nand mothers of children under one year of age, were the means by which data were gathered. Both process and outcome indicators were identified as means of assessing the effectiveness of the strategy. Vaccination rosters and holding of a town meeting were used as evidence of the former. A vaccination coverage survey using a cluster sample methodology was used to evaluate differences in vaccination coverage. Results showed that knowledge about vaccination, treatment of side effects and the importance of the RTH Card was greater among chiefs/TMs and mothers in the intervention districts than in control districts. Coverage rates for fully immunized children were greater in the intervention districts (56% intervention vs. 45% control). When stratified by type of leadership, coverage rates were higher in intervention districts where TMs rather than chiefs served as vaccination team extenders, although chiefs were more effective than controls. As a result of this study, the Ministry of Health has decided to extend this activity into other counties and to add additional information on other PHC messages.

Immunization drop-outs and maternal behavior: evaluation of reasons given and strategies for maintaining gains made in the national vaccination campaign in liberia.

Through annual National Vaccination Weeks, Liberia, one of thirteen African countries participating in the CCCD program, has achieved good rates of initial vaccination coverage against childhood diseases. However, rates of completion have been disappointing. Described is a community-based operations research methodology for a.) identifying reasons for non-completion of the vaccination series according to groups of mothers, front-line health workers and country level administrators, b.) for making recommendations for alternatives in the delivery system, and c.) for critiquing the focus group methodology as a tool for increasing commitment to program goals.