Using quality improvement approach to address missed opportunities for vaccination in Kano Metropolis, Nigeria

Adamu, Abdu Abdullahi (2019-12)

Thesis (PhD)--Stellenbosch University, 2019.

Thesis

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.

AFRIKAANSE OPSOMMING : Agtergrond Strategieë om verlore inentingsgeleenthede (VIG) te verminder, kan moontlik inentingsdekking in gesondheidsorgfasiliteite verhoog en uiteindelik inentingsdekking op distriks- en nasionale vlakke verbeter. Nietemin is daar ’n gebrek aan gesintetiseerde literatuur oor VIG in Afrika, ofskoon dit die streek met die laagste immuniseringsdekking wêreldwyd is. Ondanks die toenemende gebruik van gehalteverbetering (GV) in gesondheidfasiliteite om probleemoplossing in die gesondheidstelsel te bespoedig, bestaan daar min bewyse dat die immunisering-substelsel GV gebruik om VIG te verminder. Verder is dit onduidelik hoe die GV-benadering in ’n omgewing van laehulpbron- en lae-immunisering-dekking, soos Kano in Nigerië, toegepas kan word. Hierdie projek voorsien bewyse ten opsigte van die las en dinamika van VIG in Afrika, sowel as die mate waartoe praktisyns in gesondheidsorgfasiliteite van GV gebruik maak om VIG aan te pak. ’n GV-program is vervolgens geïmplementeer en geëvalueer, wat gemik is op die vermindering van VIG in die Nassarawa Plaaslike Owerheidsgebied (POG) in die staat Kano, Nigerië. Metodologie ’n Kombinasie van metodes, ingesluit stelselmatige oorsig, bestekbepaling, veelvlakmodellering, kwalitatiewe ondersoek, tydreeks, en gemengde metodes, is gebruik. Resultaat In die eerste komponent van die eerste fase, ’n stelselmatige oorsig, het dit aan die lig gekom dat VIG algemeen voorkom onder kinders van 0 tot 23 maande wat kontak gehad het met gesondheidsfasiliteite in Afrika, met ’n saamgevoegde voorkoms van 27,26%. Daar is egter slegs 20 VIG-evaluerings vir 14 Afrikalande gevind. Die redes vir VIG was multifaktoriaal en kompleks van aard omdat hul onderling verwant en interafhanklik is. In die tweede komponent van die eerste fase, ’n bestekbepaling, het dit aan die lig gekom dat daar wel bewyse bestaan vir die gebruik van GV om VIG te verminder en immunisasie-dekking in gesondheidsfasiliteite te verbeter. Die GV-intervensies wat opgespoor is, is egter almal in die Verenigde State geïmplementeer. Die algemeenste modelle wat gebruik is, was die Beplan-Doen-Bestudeer-Handel- (BDBH-)siklusse. In hierdie GV-programme het praktisyns veelvuldige veranderingsidees gelyktydig toegepas. Die veranderingsidees was kliënt-verwant, gesondheidswerker-verwant, asook dwarssnydende gesondheidstelsel-verwante veranderingsidees. Die tweede fase was die voorimplementeringsperiode van ’n GV-program in Kano, Nigerië. Die eerste komponent van die tweede fase, ’n deursneestudie, dui op ’n VIG-voorkoms van 36,15% onder kinders van 0 tot 23 maande, wat die primêregesondheidsorg- (PGS-)fasiliteite in die Nassarawa POG in Kano, Nigerië, besoek het. VIG kom meer algemeen voor onder kinders wat deur ’n versorger na die gesondheidsfasiliteit vergesel word en kinders wat die kliniek vanweë ’n nie-inentingsrede (soos behandeling) besoek. In die tweede komponent van hierdie fase het ’n kwalitatiewe studie, gebaseer op die ervarings van versorgers, getoon dat die nie-sifting van die inentingsgeskiedenis, die weiering om inenting aan te bied, die man se weiering, en vrees vir newe-effekte, vir VIG verantwoordelik was. In die derde fase is plaaslik-relevante veranderingsidees in vyf PGS-fasiliteite in die Nassarawa POG geïmplementeer om die geïdentifiseerde faktore mee aan te pak. In die eerste komponent van die derde fase het gesondheidswerkers in die voorste linie in hierdie fasiliteite stelselmatig veranderingsidees uitgekies en geïmplementeer in twee BDBH-siklusse wat vier weke uit mekaar geskeduleer is. Deur die gebruik van p-grafieke is die vermindering van die proporsie VIG’s per dag in twee fasiliteite in die sesde week ná die implementering van die BDBH-siklusse waargeneem. Daarna het ’n evaluering van die implementeringskonteks uitgewys dat verskeie fasiliteerders en hindernisse die implementering van die GV-program beïnvloed. Gevolgtrekking Hierdie studie bevestig dat VIG ’n algemene immuniseringsprobleem in Kano is, soos in ander omgewings in Afrika. ’n Onder-na-bo-benadering tot GV vir die aanpak van VIG, gelei deur gesondheidswerkers in fasiliteite, is haalbaar in hierdie omgewing. Snelle evaluering van die mplementeringskonteks moet egter by die GV-proses ingebou word.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/107226
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