Doctoral Degrees (Epidemiology and Biostatistics)

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Browsing Doctoral Degrees (Epidemiology and Biostatistics) by browse.metadata.advisor "Gadanya, Muktar A."

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    Using quality improvement approach to address missed opportunities for vaccination in Kano Metropolis, Nigeria
    (Stellenbosch : Stellenbosch University, 2019-12) Adamu, Abdu Abdullahi; Wiysonge, Charles S.; Uthman, Olalekan A.; Gadanya, Muktar A.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY : Background Strategies to reduce missed opportunities for vaccination (MOV) can potentially increase immunization coverage in health facilities and invariably improve immunization coverage at the district and national level. Yet, there is a dearth of synthesized literature on MOV in Africa, despite being the region with the lowest immunization coverage globally. Furthermore, the use of quality improvement (QI) in health facilities to rapidly address health system problems is growing, but evidence of its use in the immunization sub-system to reduce MOV is scarce. Moreover, it is unclear how the QI approach can be applied in a low resource, low immunization coverage setting like Kano, Nigeria. Therefore in this project, empirical evidence on the burden and dynamics of MOV in Africa was generated as well as the extent to which practitioners in healthcare facilities have used QI to address it. This was followed by the implementation and evaluation of a QI programme to reduce MOV in Nassarawa Local Government Area, Kano State, Nigeria. Methodology A combination of methods including systematic review, scoping review, multilevel modelling, qualitative inquiry, time series, and mixed methods were used. Result The first component of the first phase, a systematic review, revealed that MOV is common among children aged 0 – 23 months who made contact with health facilities in Africa, with a pooled prevalence of 27.26%. However, only 20 MOV assessments from 14 African countries were found. The reasons for MOV were multifactorial and complex because they were interrelated and interdependent. The second component of the first phase, a scoping review, revealed that evidence on the use of QI to reduce MOV and improve immunization coverage in health facilities exists. However, the QI interventions that were found were all implemented in the United States. Plan-do-study-act (PDSA) cycles were the most commonly used models. In these QI programmes, practitioners used multiple change ideas simultaneously. The change ideas were client-related, health worker-related, and cross-cutting health system-related change ideas. The second phase was the pre-implementation period of a QI programme in Kano, Nigeria. The first component of the second phase, a cross sectional study, revealed an MOV prevalence of 36.15% among children aged 0 – 23 months who visited PHC facilities in Nassarawa Local Government Area (LGA) of Kano, Nigeria. MOV was more likely to occur among children who were accompanying a caregiver to the health facility and failure to offer vaccination on the day of clinic visit. In the second component of this phase, a qualitative study based on the lived experiences of caregivers, showed that non-screening of immunization history, refusal to offer vaccination, husband’s refusal and fear of side effects were responsible for MOV. In the third phase, locally relevant change ideas were implemented in five PHC facilities in Nassarawa LGA to address the identified factors. In the first component of the third phase, frontline health workers in these facilities systematically selected and implemented change ideas in two plan-do-study-act (PDSA) cycles that were four weeks apart. Using p-charts, reduction in proportion of MOV per day was seen in two facilities at the sixth week following implementation of the PDSA cycles. Then, an evaluation of the implementation context revealed that several facilitators and barriers influenced the implementation of the QI programme. Conclusion This study confirmed that MOV is a common immunization problem in Kano, like other settings in Africa. A bottom-up QI approach to address MOV, that is led by health workers in facilities, is feasible in this setting. However, rapid assessment of implementation context should be built into the QI process.