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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 2  |  Page : 141-146  

Process Evaluation of the Universal Immunization Program in Imphal-East District of Manipur: A Cross-Sectional Study


1 Senior Resident, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
2 Associate Professor, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
3 Professor and Head, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission24-Jul-2021
Date of Decision20-Dec-2021
Date of Acceptance22-Dec-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Dayananda Ingudam
Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal - 795 005, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1583_21

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   Abstract 


Background: Various strategies have been made to make vaccines universally available including to most hard-to-reach and vulnerable population. However, change in coverage level never reached upto expected level in spite of giving so much effort by the Govt. of India and World bodies. Therefore, there is the need to look beyond. Hence, the process evaluation of Universal Immunization Program (UIP) was conducted to evaluate the process of UIP using selected variables. Methods: A cross-sectional observation was done during the period from May 2017 to April 2020 among the 14 health-care facilities and 36 selected session sites, and interview was done to 48 health-care providers working at different levels, located in Imphal East district of Manipur. Both checklist and pretested semi-structured questioners were used for collection of data. Descriptive statistics such as frequency, proportion, and percentage were used. Results: Ice-lined refrigerator and Deep-freezer were found to be present in working condition in 11 (100%) centers. The use of vaccine carrier was found in all 36 (100%) centers. Way of vaccine administration was found to be correct in 26 (72.2%) centers. Availability of up-to-date microplan was found in 18 (78.3%) centers. Conclusions: Barriers in the UIP were not uniform throughout the villages and districts. Hence, area-specific measures need to be taken up for overcoming the barriers and challenges.

Keywords: Deep-freezer, ice-lined refrigerator, universal immunization program, vaccine preventable diseases


How to cite this article:
Ingudam D, Singh HK, Devi LU. Process Evaluation of the Universal Immunization Program in Imphal-East District of Manipur: A Cross-Sectional Study. Indian J Public Health 2022;66:141-6

How to cite this URL:
Ingudam D, Singh HK, Devi LU. Process Evaluation of the Universal Immunization Program in Imphal-East District of Manipur: A Cross-Sectional Study. Indian J Public Health [serial online] 2022 [cited 2022 Aug 16];66:141-6. Available from: https://www.ijph.in/text.asp?2022/66/2/141/350649




   Introduction Top


Immunization program is one of the key interventions program and most cost-effective health investments for the protection of children from vaccine preventable diseases globally. It saves 2–3 million lives each year and plays a central role in ending preventable child deaths. However, nearly one in five infants misses out on the basic vaccine.[1] Over 1.5 million children die annually from vaccine preventable diseases and 19.5 million children are not receiving the most basic vaccines leaving them vulnerable to dangerous diseases.[1]

The immunization program in India is one of the largest immunization programs in the world and a major public health intervention program in the country.[2] It was first introduced in 1978 as Expanded Program of Immunization and later changed to Universal Immunization Program (UIP) in 1985, which is now one of the key areas under National Rural Health Mission since 2005.[3]

Under the UIP, it was targeted to vaccinate nearly 27 million newborns each year with all primary doses and additionally about 100 million children aged 1–5 years with booster doses; for this, more than 90 lakh immunization sessions were conducted annually.[3]

Over the years, various strategies have been made to make vaccines universally available including to the most hard-to-reach and vulnerable population, but the change in the coverage level never reached up-to the desired level. For the state of Manipur, the evaluated figures as per National Family Health Survey (NFHS-2), NFHS-3, and NFHS-4 were 42.3%, 46.8%, and 65.9%, respectively.[4],[5],[6] These figures show an increasing trend but are still unsatisfactory. There is a need to look beyond, not only in terms of evaluating the vaccination coverage but also to look into how the program is being implemented. This translates into looking into the processes of the immunization program.

Imphal East District being a part of the state capital of Manipur and other districts of the state especially the hilly districts might not have fared better under the program. Hence, Imphal-East district was selected as the study area for the current study to evaluate the process of UIP using selected variables.


   Methods Top


Study design, setting, and study participants

This descriptive cross-sectional observational study was conducted during the period of May 2017–April 2020 at 14 health facilities, 36 selected vaccination session sites, and among 48 key health-care providers working at different level of health-care facilities located in Imphal-East district of Manipur.

Sample size and selection of participants

The study population consisted of the sole District Immunization officer (DIO), Senior Medical officer (1) in-charge (SMO i/c-), Medical officers (12) in-charge (MOs i/c) of all the existing Community Health Centre (CHC), Primary Health Centres/Urban Health Centres (PHCs/UPHCs), 11 Female Health supervisors (FHSs) of CHC and PHCs, 10 Auxiliary Nurse Midwife (ANMs) in-charge of Sub-Centers (SCs), and 13 Accredited Social Health Activists (ASHAs). Multistage sampling technique was used for the selection of study participants. First, the sole DIO of the Imphal-East district was selected and then SMO i/c of CHC, all MOs in-charge of PHCs and UPHSs of Imphal-East were selected. This was followed by selection of one SCs each from the selected CHC/PHCs/UPHSs by lottery method. Then, one village/ward from each of the selected SCs using the same method was selected. Finally, all ASHAs working in the selected villages were included in the study.

Data collection: Tools and techniques

The collection of data was done by observation and interview schedule. Checklist was used for observation of 14 vaccine storage sites, 36 different vaccination session sites, and 23 health-care facilities for the availability of microplan copies for the current year. Pretested semi-structured interview schedules were made by researchers by reviewing related articles and this were used by investigators during data collection for the various categories of healthcare providers. Pretesting was conducted to a handful of health-care providers working in the adjacent district (Imphal-West).

The key process evaluation indicators used in the study were availability of staffs trained on routine immunization, health facilities having adequate vaccine and ancillaries, health facilities with proper cold-chain maintenance system, having updated micro-plans, presence of beneficiary mobilizer, correctly identifying the contraindications, giving four key message after vaccination, way of vaccine administration, injection-safety practices, reporting of adverse events following immunization, immunization-related supervisory visits, etc.

Operational definition

Outreach sessions

Sessions held in a location other than a health facility where workers can go out and return the same day.[7]

Statistical analysis

Data collected were entered first in Microsoft excel sheet and checked for consistency. Data analysis was done with Statistical Package for the Social Sciences version 20 (IBM company, Chicago, Illinois, United States). Descriptive statistics such as frequency, proportion, and percentage were used.

Ethical clearance

Ethical approval was obtained from the Institutional Ethics Committee, JNIMS, Imphal vide the registration no. Ac/06/IEC/JNIMS/2017 (PGT) study Protocol No. 61 (17) PGT 2017 dated the August 24, 2017 before beginning of the study. Verbal informed consent was also taken from all the study participants after informing them the purpose of the study.


   Results Top


The district vaccine storage site, the sole CHC, all existing 12 PHCs/UPHCs, 36 vaccination session sites which were One CHC, 10 PHCs, 2 UPHCs, 10 SCs, 13 outreach sessions, and 23 health-care facilities for the availability of microplan copies for the current year. Interviews were also conducted in 48 different health-care providers which include the DIO, 13 SMO/MOs i/c, 11 FHSs, 10 ANM in-charges of selected SCs, and 13 ASHAs working under selected villages.

Out of the 14 vaccine storage sites included in the study, 11 (78.6%) had both ice-lined refrigerator (ILR) and deep-freezer (DF) in working condition. Stacking vaccine vials inside DF/ILR was correct in 9 (81.8%) of the health facilities. Temperature monitoring was done twice daily in all the 11 (100%) health facilities [Table 1].
Table 1: Observation of vaccine storage site, vaccination session sites and for avalability of micro-plan

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ASHAs were present as mobilizers in all the 36 vaccination session sites. Some errors [Table 1] were also observed in those vaccination sessions: Not recording time of vaccine reconstitution in 11 (30.6%), incorrect way of vaccine administration in 10 (27.8%), absent of colour-coded disposal bags in 6 (16.7%), and not treating the sharp waste materials with disinfectant in 25 (69.4%).

Upto-to-date micro-plan was present in 18 (78.3%) of the 23 health facilities (CHC/PHC/UPHC/SC) observed [Table 1].

At the district head quarter level, there was no shortage of vaccines, AD syringes, and colour-coded bins/bags during the last 1 year. Shortage of ILR, DF, CB, VC, hubcutter, and reporting of improportionately higher acheivement report by two UPHCs were present. Tracking of missed-out cases and field supervisory visit were also conducted [Table 2].
Table 2: Reported strength and limitation at district headquarter level (n=1) and at mid-managerial community health centre, primary health centres and urban primary health centres level (n=13)

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At the mid-managerial level (CHC, PHC and UPHC), shortage of Vaccines, AD syringes and cold chain equipments were reported from 2 (15.4%), 4 (30.8%) and 3 (23.1%) in-charges of health facilities respectively. Tracking of missed-out cases was done at all 13 (100%) health centres. 10 (79.9%) of the MO i/cs were aware of microplan prepared by SC ANM. 9 (69.2%) of these health facilities were having hard-to-reach wards/villages. The field supervisory visit was reported to be done by 12 (92.3%) incharges of the CHC/PHCs/UPHC [Table 2].

Out of the total 11 FHSs interviewed, 9 (81.8%) of them were trained in UIP. 9 (81.8%) were also found to be giving supervisory visits in the field and mentioned on immunization related activities [Table 3].
Table 3: Reported strength and limitation faced by female health supervisors (11) and sub.centres auxiliary nurse midwife (10)

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Out of ten SCs ANM interviewed in the study, 6 (60%) of them were reported to be trained on UIP. 3 (30%) were reported as having other villages under their jurisdiction. Mobilization of beneficiaries was reported to be done by ASHAs in all 10 (100%) SCs. Use of color-coded bags was found in 3 (30%) SCs and correct way of waste disposal 1 (10%) SC. 8 (80%) of the SCs were reported to have been visited by FHSs and 7 (70%) of them by SMO/MO i/c in the past 1 year [Table 3].

All ASHAs used to work on mobilization for immunization as main activity. Complication after vaccination was reported by two (15.4%) ASHAs. Difficulty in mobilizing children for vaccination was reported in six (46.2%) villages [Table 4].
Table 4: Informations gather from selected accredited social health activist (n=13)

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   Discussion Top


The present study explores the various merits and demerits that existed in the process part of the UIP at different level of health-care facilities, session sites, and health-care providers of Imphal-East areas for improving the immunization performance. Of the 14 health facilities observed, 11 (78.6%) of them have ILR and DF in working condition with generator backup. Similar findings were also reported by Nandan et al., in which 78% of the centers have functional ILR and DF.[8] While Nath et al. have reported 100% of the Cold chain points as having ILR and DF in functional conditions and no alternate electric supply in 3 of the 11 cold chain centers.[9] A different findings was reported by LalithaKrishnappa et al., in which 57 (84%) and 43 (63%) centers in Bruhat Bangalore Mahanagare Pallike had ILR and DFs respectively and out of 35 unit samples, 33 (94%) and 32 (91%) of centers have at least one functional ILR and DF, respectively.[10] The reasons for the differences in these different studies could be due to difference in study setting or health facility level.

In the present study, temperature monitoring charts as well as frequency of temperature monitoring was done twice daily in the 11 (100%) health facilities. This finding was in concordance with that of studies reported by Naik et al., in which all the 20 UHCs of Surat Municipal Corporation recorded temperature monitoring twice a day for both DF and ILR.[11] This finding was more than that as reported by Nath et al. (36%), Yakun et al.(50%), and Mallik et al.(60%).[9],[12],[13] Better findings reported in the study could be due to better performance in terms of supervision made by the superior staffs and better knowledge level of the cold chain handlers.

In this study, stacking vaccine vials inside DF/ILR was found to be correct in 9 (81.8%) health facilities. Sinha et al. monitored 20 cold points in Chhattisgarh and found T-series vaccines placed properly in 17 Cold chain Points (85%).[14] Other studies highlighted similar observations, ranging from 66.6% to 93.2% of cold chain points.[11],[14],[15],[16]

In the current study, ASHAs were present as mobilizer in all 36 (100%) vaccination sites. Vaccine carriers were also used in all 13 (100%) outreach session. All vaccine carriers had four ice-packs inside them. This is consistent with that reported by Parmer A, in which all the 13 SCs in Vadodara District has vaccine carriers with four conditioned ice-packs;[17] Billah et al. reported only in 17% using it in outreach vaccination sites.[18]

In the present study, all vaccine carriers were placed in shaded areas at all 13 (100%) outreach session sites. Placement of reconstituted vaccine on ice-pack was found in 34 (94.4%) vaccination sites. Advice given after vaccination like when to come back again was given in 12 (33.3%) session sites. Some other modifiable areas were also noted such as marking time of vaccine reconstitution in 11 (30.6%), incorrect way of vaccine administration in10 (27.8%), absence of colour coded disposal bags or bins in 6 (16.7%), not using needle hub-cutter in 12 (33.3%), and treatment of sharp-waste materials not done in 25 (69.4%). Parmer et al. reported that the date and time of opening of Measles and BCG vials were not noted by FHWs at 5 (38.5%) sessions sites, while time of reconstitution written on BCG and Measles vials was seen in 8 (61.5%) session sites. They also reported correct methods for waste collection, all AD and Disposable syringes were cut with hub-cutter immediately after use and ANM gave the four key messages at 10 (77%), 11 (84.6%), and 6 (44%) session sites, respectively.[17] Sharma et al. have reported time of reconstitution recorded on the vial (BCG/Measles) in 41 (82%) session sites, while correct administration of vaccines, availability of hubcutters at the session sites, and key messages given to mother were recorded in 50 (100%), 39 (78.0%), and 47 (94.0%), respectively.[15] A similar study was conducted by Algotar et al. in 60 session sites in Ahmedabad district; they found that in three (5%) session sites, ANMs were not cutting syringes immediately after use with hubcutter.[19]

In the present study, up-to-date microplan was present in 18 (78.3%) health facilities. Other studies reported sessions being held as per microplan at all (100%) the sessions.[17],[19] This could be due to the differences in study setting and level of management.

At the mid managerial level, field supervisory visits were reported in 12 (92.3%) health centers and 10 (79.9%) health facilities were aware of micro-plan prepared by SC ANMs. However, shortage of vaccine, AD syringes, and cold chain equipment was reported in 2 (15.4%), 4 (30.8%), and 3 (23.1%) health facilities, respectively. Sharp biomedical waste disposal pit was present in 9 (69.2%) centers. In a study conducted in 13 sites by Parmar et al., supervisory visits were reported only in 3 (23%) sites, while Sharma et al. reported supervisory field visits details for sessions in a year available in 29 (58%) sites and supervisory visits by district officials in 20 (40%) sites.[15],[17] Correct method for waste collection was reported in 10 (77%) session sites by Parmer et al., while Sharma et al. reported disposal pit available in 46 (92%) sites and Nath et al. reported disposal pits in 2 CHCs and no pits for disposal of sharps in the PHCs.[9],[15],[17] These reflect poor management and supervision by supervisory cadres.

In the current study, 9 (69%) of the health facilities were hard-to-reach wards/villages including hilly areas, poor transportation, and communication.

The present study found that majority of the advice at SCs level after vaccination included: when to come back again in 5 (50%) and about possible complications and management in 4 (40%). Algotar et al. reported that the four key messages were not given to caregivers by 8 (13.33%) ANMs.[19] This may be because of the differences in their knowledge levels and lack of training of the healthcare providers.

According to the NFHS-5 survey report, there has been a considerable improvement in full vaccination coverage among children age 12–23 months in the states of Gujarat, Nagaland, Mizoram, Karnataka, and Assam. However, there has not been a significant improvement in full vaccination coverage for Manipur (68.8%).[20] Our study offers some possible explanations.


   Conclusion Top


From the present study, it was known that there was a lot of improvement in process part of UIP in Imphal East District of Manipur, but still some certain areas needs improvement such as the area of infrastuctures, logistic, regular time-to-time training of health-care providers on immunization, regular supervisory visit by FHSs and SMO/MOs, regular updating of micro-plan, etc., Barriers in the UIP were also found to be not uniform in most of the villages present in the Imphal-East District.

To overcome the various loopholes highlighted in the present study findings, it is of utmost important that an effective and better policies related to immunization is implemented at the local level. Monitoring and evaluation component of the program should also be carried out effectively in order to improve immunization performance. Our study findings will also draw the attention of various stakeholders, policymakers, non-governmental organization, s and concerned government authorities for implementing better policies and programmes for the benefit of the overall society.

Ethical approval

Ethical approval obtained from the Institutional Ethical Committee with registration No. Ac/06/IEC/JNIMS/2017 (PGT).

Acknowledgments

We are very grateful to DIO of Imphal-East, staff of Rural Health Mission and Medical Officers in-charge of health centers of Imphal-East for sharing their valuable and precious time during our data collection period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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