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Improving immunization capacity in Ethiopia through continuous quality improvement interventions: a prospective quasi-experimental study.

ABSTRACT: BACKGROUND:Strong scientific evidence is needed to support low-income countries in building effective and sustainable immunization programs and proactively engaging in global vaccine development and implementation initiatives. This study aimed to implement and evaluate the effectiveness of system-wide continuous quality improvement (CQI) interventions to improve national immunization programme performance in Ethiopia. METHODS:The study used a prospective, quasi-experimental design with an interrupted time-series analysis to collect data from 781 government health sectors (556 healthcare facilities, 196 district health offices, and 29 zonal health departments) selected from developing and emerging regions in Ethiopia. Procedures included baseline quality assessment of immunization programme and services using structured checklists; immunization systems strengthening using onsite technical support, training, and supportive supervision interventions in a Plan-Do-Check-Act cycle over 12?months; and collection and analysis of data at baseline and at the 6th and 12th month of interventions using statistical process control and the t-test. Outcome measures were the coverage of the vaccines pentavalent 3, measles, Bacillus Calmette-Guérin vaccine (BCG), Pneumococcal Conjugate Vaccine (PCV), as well as full vaccination status; while process measures were changes in human resources, planning, service delivery, logistics and supply, documentation, coordination and collaboration, and monitoring and evaluation. Analysis and interpretation of data adhered to SQUIRE 2.0 guidelines. RESULTS:Prior to the interventions, vaccination coverage was low and all seven process indicators had an aggregate score of below 50%, with significant differences in performance at healthcare facility level between developing and emerging regions (P =?0.0001). Following the interventions, vaccination coverage improved significantly from 63.6% at baseline to 79.3% for pentavalent (P =?0.0001), 62.5 to 72.8% for measles (P =?0.009), 62.4 to 73.5% for BCG (P =?0.0001), 65.3 to 81.0% for PCV (P =?0.02), and insignificantly from 56.2 to 74.2% for full vaccination. All seven process indicators scored above 75% in all regions, with no significant differences found in performance between developing and emerging regions. CONCLUSIONS:The CQI interventions improved immunization capacity and vaccination coverage in Ethiopia, where the unstable transmission patterns and intensity of infectious diseases necessitate for a state of readiness of the health system at all times. The approach was found to empower zone, district, and facility-level health sectors to exercise accountability and share ownership of immunization outcomes. While universal approaches can improve routine immunization, local innovative interventions that target local problems and dynamics are also necessary to achieve optimal coverage.

SUBMITTER: Manyazewal T

PROVIDER: S-EPMC6267782 | biostudies-other | 2018 Nov

REPOSITORIES: biostudies-other

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Improving immunization capacity in Ethiopia through continuous quality improvement interventions: a prospective quasi-experimental study.

Manyazewal Tsegahun T Mekonnen Alemayehu A Demelew Tesfa T Mengestu Semegnew S Abdu Yusuf Y Mammo Dereje D Abebe Workeabeba W Haffa Belay B Zenebe Daniel D Worku Bogale B Aman Amir A Tigabu Setegn S

Infectious diseases of poverty 20181130 1

<h4>Background</h4>Strong scientific evidence is needed to support low-income countries in building effective and sustainable immunization programs and proactively engaging in global vaccine development and implementation initiatives. This study aimed to implement and evaluate the effectiveness of system-wide continuous quality improvement (CQI) interventions to improve national immunization programme performance in Ethiopia.<h4>Methods</h4>The study used a prospective, quasi-experimental design ...[more]

PMID: 30497515

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Project description:IntroductionGreat improvements in the health of newborns, children, and women in Pakistan are needed. A large body of literature has demonstrated that the majority of maternal, newborn, and child deaths are preventable with essential health strategies including immunization, nutrition interventions, and child health interventions. Despite the importance of these interventions for the health of women and children, access to services continues to be a barrier. Furthermore, demand for services also contributes to low coverage of essential health interventions. Given the emerging threat of COVID-19 coupled with already weak maternal and child health, delivering effective and feasible nutrition and immunization services to communities, and increasing demand and uptake of services is a pressing and important need.Methods and analysisThis quasi-experimental study aims to improve health service delivery and increase uptake. The study included four main intervention strategies including community mobilization, mobile health teams offering MNCH and immunization services, engagement of the private sector, and testing of a comprehensive health, nutrition, growth, and immunization app, Sehat Nishani, for a period of 12 months. The target group of the project were women of reproductive age (15-49 years) and children under-five. The project was implemented in three union councils (UCs) in Pakistan including Kharotabad-1(Quetta District, Balochistan), Bhana Mari (Peshawar District, Khyber Pakhtunkhwa) and Bakhmal Ahmedzai (Lakki Marwat district, Khyber Pakhtunkhwa). Propensity score matching based on size, location, health facilities, and key health indicators of UC was conducted to identify three matched UCs. A household baseline, midline, endline and close-out assessment will be conducted for evaluating coverage of interventions as well as the knowledge, attitude, and practices of the community in the MNCH and COVID-19 context. Descriptive and inferential statistics will be used to test hypotheses. As well, a detailed cost-effectiveness analysis will be conducted to generate costing data for these interventions to effectively inform policymakers and stakeholder on feasibility of the model. Trial registration: NCT05135637.

Project description:ContextContinuous quality improvement (CQI) has become prominent in public health settings; yet, little consolidated guidance exists for building CQI capacity of community-based organizations.ObjectiveTo synthesize relevant literature to identify guiding principles and core components critical to building the capacity of organizations to adopt and use CQI.DesignWe employed a systematic review approach to assess guiding principles and core components for CQI capacity-building as outlined in the literature.Eligibility criteriaStudies meeting the following criteria were eligible for review: (1) empirical, peer-reviewed journal article, evaluation study, review, or systematic review; (2) published in 2010 or later; and (3) capacity-building activities were described in enough detail to be replicable. Studies not including human subjects, published in a language other than English, or for which full text was not available were excluded.Study selectionThe initial return of records included 6557 articles, of which 1455 were duplicates. The research team single-screened titles and abstracts of 5102 studies, resulting in the exclusion of 4842 studies. Two hundred sixty-two studies were double-screened during full-text review, yielding a final sample of 61 studies from which data were extracted.Main outcome measuresOutcome measures of interest were operationalized descriptions of guiding principles and core components of the CQI capacity-building approach.ResultsResults yielded articles from medical education, health care, and public health settings. Findings included guiding principles and core components of CQI capacity-building identified in current practice, as well as infrastructural and contextual elements needed to build CQI capacity.ConclusionsThis consolidation of guiding principles and core components for CQI capacity-building is valuable for public health and related workforces. Despite the uneven distribution of articles from health care, medical education, and public health settings, our findings can be used to guide public health organizations in building CQI capacity in a well-informed, systematic manner.

Project description:ObjectiveTo demonstrate the impact of interventions on tuberculosis (TB) case detection in mining and pastoralist districts in southeastern Ethiopia over a 10-year period.DesignLongitudinal quasi-experimental study.SettingHealth centres and hospitals in six mining districts implemented interventions and seven nearby districts functioned as controls.ParticipantsData from the national District Health Information System (DHIS-2) were used for this study; therefore, people did not participate in this study.InterventionsDirected at training, active case finding and improving treatment outcomes.Primary and secondary outcome measuresPrimarily, trends in TB case notification and percentage of bacteriologically confirmed TB-as collected by DHIS-2-between pre-intervention (2012-2015) and post-intervention (2016-2021) were analysed. Secondarily, post-intervention was split into early post-intervention (2016-2018) and late post-intervention (2019-2021) to also study the long-term effects of the intervention.ResultsFor all forms of TB, case notification significantly increased between pre-intervention and early post-intervention (incidence rate ratio (IRR): 1.21, 95% CI: 1.13, 1.31; p<0.001) and significantly decreased between pre-intervention/early post-intervention and late post-intervention (IRR: 0.82, 95% CI: 0.76, 0.89; p<0.001 and IRR: 0.67, 95% CI: 0.62, 0.73; p<0.001). For bacteriologically confirmed cases, we found a significant decrease between pre-intervention/early post-intervention and late post-intervention (IRR: 0.88, 95% CI: 0.81, 0.97; p<0.001 and IRR: 0.81, 95% CI: 0.74, 0.89; p<0.001). The percentage of bacteriologically confirmed cases was significantly lower in the intervention districts during pre-intervention (B: -14.24 percentage points, 95% CI: -19.27, -9.21) and early post-intervention (B: -7.78, 95% CI: -15.46, -0.010; p=0.047). From early post-intervention to late post-intervention, we found a significant increase (B: 9.12, 95% CI: 0.92 to 17.33; p=0.032).ConclusionsThe decrease in TB notifications in intervention districts during late post-intervention is possibly due to a decline in actual TB burden as a result of the interventions. The unabated increase in case notification in control districts may be due to continued TB transmission in the community.

Project description:BackgroundIncreasing nutrient intake through home gardening is a sustainable way to address multiple micronutrient deficiencies in developing countries. This study investigated the impact of permagarden intervention in increasing the frequency and diversity of vegetable and fruit consumption among vulnerable families in seven cities of Ethiopia.MethodA quasi-experimental study was conducted from August 10 to September 30, 2015. A total of 884 care givers (427 from intervention and 457 from control) participated in the study. Data were collected through face to face interviews with caregivers of highly vulnerable children. Propensity score matching (PSM) was used as implemented in STATA software. Program impact on the frequency and diversity of households' fruit and vegetable consumption between intervention and control groups was assessed using chi square test.ResultsIntervention participants had a 13% higher increase in frequency of vegetable and fruit consumption compared with control participants (p<0.01). Diversity (consumption of 2 or more groups of vegetable and fruit) is higher among intervention groups than control groups (percentage difference = 9, p-value<0.05). A significant higher percentage of participants in intervention group reported getting the one-week vegetable and fruit mainly from their own garden (percentage difference 58.3%, p<0.05). A significantly larger proportion of participants in the intervention group compared to control group reported "high likelihood" on intention to grow vegetables in the future (percentage difference = 30%, and P<0.01). Perceived importance to include vegetable in everyday meal was higher among intervention group participants than control group participants (percentage difference = 11.5%, P<0.01).ConclusionsThe observed higher FV intake among permagarden intervention group compared to control group suggest that nutrition and health programs need to promote permagarden as a means to improve FV intake among vulnerable societies in resource limited countries.

Project description:BackgroundEvidence-based medicine (EBM) bridges research and clinical practice to enhance medical knowledge and improve patient care. However, clinical decisions in many African countries don't base on the best available scientific evidence. Hence, this study aimed to determine the effect of training interventions on background knowledge and awareness of EBM sources, attitude, competence, and practice of EBM among healthcare professionals.MethodWe designed a controlled group quasi-experimental pre-post test study to evaluate the effect of capacity-building EBM training. A total of 192 healthcare professionals were recruited in the study (96 from the intervention and 96 from the control group). We used a difference-in-differences (DID) analysis to determine the effect of the training. Along the way, we used a fixed effect panel-data regression model to assess variables that could affect healthcare professionals' practice of EBM. The cut point to determine the significant effect of EBM training on healthcare professionals' background knowledge and awareness of EBM sources, attitude, and competence was at a P-value < 0.05.ResultThe DID estimator showed a significant net change of 8.0%, 17.1%, and 11.4% at P < 0.01 on attitude, competence, and practice of EBM, respectively, whereas no significant increment in the background knowledge and awareness of EBM sources. The fixed effect regression model showed that the attitude [OR = 2.288, 95% CI: (1.049, 4.989)], competence [OR = 4.174, 95% CI: 1.984, 8.780)], technical support [OR = 2.222, 95% CI: (1.043, 3.401)], and internet access [OR = 1.984, 95% CI: (1.073, 4.048)] were significantly affected EBM practice.ConclusionThe capacity-building training improved attitude, competence, and EBM practice. Policymakers, government, and other concerned bodies recommended focusing on a well-designed training strategy to enhance the attitude, competence, and practice towards EBM among healthcare professionals. It was also recommended to enhance internet access and set mechanisms to provide technical support at health facilities.

Project description:BackgroundTo improve quality of care for patients with hip and knee osteoarthritis (OA), general practitioners (GPs) and physiotherapists (PTs) in a Norwegian municipality initiated an intervention. The intervention aimed to increase provision of core OA treatment (information, exercise, and weight control) prior to referral for surgery, rational use of imaging for assessing OA and improve communication between healthcare professionals. This study assessed the effectiveness of this intervention.MethodsForty-eight PTs and one hundred one GPs were invited to the intervention that included two interactive workshops outlining best practice and an accompanying template for PT discharge reports. Using interrupted time series research design, the study period was divided into three: pre-implementation, transition (implementation) and post-implementation. Comparing the change between pre- and post-implementation, the primary outcome was patient-reported quality of OA care measured with the OsteoArthritis Quality Indicator questionnaire. Secondary outcomes were number of PT discharge reports, information included in GP referral letters to orthopaedic surgeon, the proportion of GP referral letters indicating use of core treatment, and the use of imaging within OA assessment. Analyses involved linear mixed and logistic regression models.ResultsThe PT workshop had 30 attendees, and 31 PTs and 33 GPs attended the multidisciplinary workshop. Two hundred eight and one hundred twenty-five patients completed the questionnaire during pre- and post-implementation, respectively. The adjusted model showed a small, statistically non-significant, increase in mean total score for quality of OA care (mean change = 4.96, 95% CI -0.18, 10.12, p:0.057), which was mainly related to items on OA core treatment. Patients had higher odds of reporting receipt of information on treatment alternatives (odds ratio (OR) 1.9, 95% CI 1.08, 3.24) and on self-management (OR 2.4, 95% CI 1.33, 4.32) in the post-implementation phase. There was a small, statistically non-significant, increase in the proportion of GP referral letters indicating prior use of core treatment modalities. There were negligible changes in the number of PT discharge reports, in the information included in the GP referral letters, and in the use of imaging for OA assessment.ConclusionThis study suggests that a primary care intervention including two inter-active workshops can shift the quality of care towards best practice recommendations.Trial registrationClinicalTrials.gov: NCT02876120 .

Project description:Globally, unmet need for postpartum family planning is high. However, immunization services are among the most widely utilized health services. Establishing systematic screening, counseling, and referral systems from different contact points, particularly from EPI units may improve postpartum family planning uptake. Hence, this study aimed to assess the effect of counseling for family planning at EPI units on contraceptive uptake during the extended post-partum period. A before-and-after type of quasi-experimental study was conducted in 8 purposively selected primary health care units in Sidama region, Ethiopia. All mothers visiting the selected health facilities for infant immunization services from February 06 to August 30, 2020, were screened, counseled, and referred for family planning. A structured interviewer-administered questionnaire was used to collect data from 1421 randomly selected mothers (717 for pre-intervention and 704 post-intervention phases). EpiData version 3.1 and SPSS version 22 were used for data entry and analysis. The effect of the intervention was assessed using multivariable logistic regression analysis adjusting for the effects of potential confounders. P value < 0.05 was considered statistically significant. The contraceptive utilization rate before intervention was 72.7% with 95% CI (69.5, 75.9). It was 91.9%, 95% CI (89.8%, 93.9%) after the intervention. Utilization of contraceptive pills increased from 4.3% to 6.9%, injectables from 52.4% to 57.5%, implants from 12.8% to 22.9%, and IUCD from 3.2% to 5.0% after the intervention. After adjusting for the effect of possible confounding variables, screening, counseling, and referring mothers for family planning at infant immunization units significantly increases the contraceptive utilization rate among mothers presented for infant immunization services(AOR = 5.83, 95% CI: 4.02, 8.46). Screening, counseling, and referring mothers for family planning services at infant immunization units significantly increases postpartum contraceptive uptake. Integrating family planning messages with infant immunization services is recommended. Trial registration: ClinicalTrials.gov Identifier: NCT04767139 (Registered on 23/02/2021).

Project description:Trachoma is chronic kerato conjunctivitis, which is caused by repeated infection with Chlamydia trachomatis bacterium. It is hyper endemic in many rural areas of Ethiopia. The objective of this study was to measure the effect of water, sanitation and hygiene interventions on active trachoma in selected woredas of North and South Wollo zones of Amhara Region, Ethiopia.A community based quasi-experimental study was conducted from October 2014 to December 2015 among children aged 1-8 years at baseline and among one year older same children after intervention. A four-stage random cluster-sampling technique was employed to select study participants. From each selected household, one child was clinically assessed for active trachoma. Structured questionnaire was used to collect socio demographic and behavioral data. MacNemar test was applied to compare the prevalence of active trachoma between baseline and after the intervention period at both intervention and non-intervention study areas.The prevalence of active trachoma was reduced from baseline prevalence of 26% to 18% after one-year intervention period in the intervention woredas (P?0.001). MacNemar test result showed significant reduction of active trachoma prevalence after the intervention period in the intervention woredas compared to the non-intervention woredas (P?0.001). Water, sanitation and hygiene related activities were significantly improved after the intervention period in the intervention woredas (P<0.05).There was a significant reduction of active trachoma prevalence between the baseline and after the intervention period in the intervention woredas, but not in the non-intervention ones. Improved water, sanitation and hygiene interventions contributed to the reduction of active trachoma. However, the magnitude of active trachoma prevalence observed after the intervention is still very high in the studied areas of North and South Wollo Zones communities. To achieve the global trachoma elimination target by the year 2020 as set by the WHO, continued WaSH interventions and periodic monitoring, evaluation and reporting of the impact of WaSH on active trachoma is warranted.

Project description:BackgroundEthiopia was among the 15 countries that, together accounted for 64% of the world's severe episodes of pneumonia among children below the age of 5 in 2011. To reduce this burden, the 10-valent pneumococcal conjugate vaccine (PCV 10) was introduced into the general childhood national immunization program in Ethiopia in 2011. However, there is little evidence on its cost-effectiveness, and the aim of this study was to estimate the cost-effectiveness of the introduction of PCV 10 vaccination in the Ethiopian setting.MethodsThe cost-effectiveness analysis was carried out based on a quasi-experimental evaluation of implementing PCV 10 at the Butajira rural health program site in Ethiopia. The intervention and the control groups consisted 876 and 1010 children, respectively. Using data from program site's surveillance system database as a framework, health outcome and vaccination data were collected from medical records, immunization registration books and reports. Disability- Adjusted Life Year (DALY) was a main health outcome metric complimented by incidence of acute lower respiratory infection/1000-person years. Vaccination and treatment costs were collected by document review and cross-sectional household survey.ResultsIn the intervention cohort, 626 of 876 (71.5%) children received PCV 10 vaccination. Until the first year of life, the incidence of acute lower respiratory infection was higher in the intervention group. After the first year of life, the incidence rate was 35.2 per 1000-person years in the intervention group compared to 60.4 per 1000-person years in the control group. The incremental cost-effectiveness ratio (ICER) per averted DALY for the intervention group during the total follow-up period was (2013 US$) 394.3 (undiscounted) and 413.8 (discounted). The ICER per averted DALY excluding the first year of life was (2013 US$) 225 (undiscounted) and 292.7 (discounted).ConclusionCompared to the WHO's suggested cost-effectiveness threshold value, the results indicate that the general childhood PCV 10 vaccination was a cost-effective intervention in the Butajira rural health program site.

Dataset Information

Improving immunization capacity in Ethiopia through continuous quality improvement interventions: a prospective quasi-experimental study.

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Improving immunization capacity in Ethiopia through continuous quality improvement interventions: a prospective quasi-experimental study.

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