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Ogutu EA, Ellis AS, Hester KA, Rodriguez K, Sakas Z, Jaishwal C, Yang C, Dixit S, Bose AS, Sarr M, Kilembe W, Bednarczyk R, Freeman MC. Success in vaccination programming through community health workers: a qualitative analysis of interviews and focus group discussions from Nepal, Senegal and Zambia. BMJ Open 2024; 14:e079358. [PMID: 38569679 DOI: 10.1136/bmjopen-2023-079358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVES Community health workers are essential to front-line health outreach throughout low-income and middle-income countries, including programming for early childhood immunisation. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunisation coverage would support evidence-based policy guidance across contexts. DESIGN We employed a multiple case study design using qualitative research methods. SETTING We conducted research in Nepal, Senegal and Zambia. PARTICIPANTS We conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility and community levels of the health systems of Nepal, Senegal and Zambia, from October 2019 to April 2021. We used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunisation within each country and across contexts. RESULTS Implementation of vaccination programming relied principally on the (1) organisation, (2) motivation and (3) trust of community health workers. Organisation was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on their work. CONCLUSION Improvements in immunisation coverage was facilitated by community health worker organisation, motivation and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to underserved populations. Although improvements in vaccination programming were seen in all three countries-including government commitment to addressing human resource deficits, training and remuneration; workload, inconsistency in compensation, training duration and scope, and supervision remain major challenges to immunisation programming. Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming.
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Affiliation(s)
- Emily A Ogutu
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Anna S Ellis
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Kyra A Hester
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Katie Rodriguez
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Zoe Sakas
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Chandni Jaishwal
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - Chenmua Yang
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Moussa Sarr
- Institut de Recherche en Santé, de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | | | - Robert Bednarczyk
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Matthew C Freeman
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
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Escoffery C, Ogutu EA, Sakas Z, Hester KA, Ellis A, Rodriguez K, Jaishwal C, Yang C, Dixit S, Bose A, Sarr M, Kilembe W, Bednarczyk RA, Freeman MC. Drivers of early childhood vaccination success in Nepal, Senegal, and Zambia: a multiple case study analysis using the Consolidated Framework for Implementation Research. Implement Sci Commun 2023; 4:109. [PMID: 37667374 PMCID: PMC10478385 DOI: 10.1186/s43058-023-00489-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION The fundamental components of a vaccine delivery system are well-documented, but robust evidence is needed on how the related processes and implementation strategies - including the facilitators and barriers - contribute to improvements in childhood vaccination coverage. The purpose of this study was to identify critical facilitators and barriers to the implementation of common interventions across three countries that have dramatically increased coverage of early childhood vaccination over the past 20 years, and to qualify common or divergent themes in their success. METHODS We conducted 278 key informant interviews and focus group discussions with public health leaders at the regional, district, and local levels and community members in Nepal, Senegal, and Zambia to identify intervention activities and the facilitators and barriers to implementation. We used thematic analysis grounded in the Consolidated Framework for Implementation Research (CFIR) constructs of inner and outer settings to identify immunization program key facilitators and barriers. RESULTS We found that the common facilitators to program implementation across the countries were the CFIR inner setting constructs of (1) networks and communications, (2) goals and feedback, (3) relative priority, and (4) readiness for implementation and outer setting constructs of (5) cosmopolitanism and (6) external policies and mandates. The common barriers were incentives and rewards, available resources, access to knowledge and information, and patients' needs and resources. Critical to the success of these national immunization programs were prioritization and codification of health as a human right, clear chain of command and shared ownership of immunization, communication of program goals and feedback, offering of incentives at multiple levels, training of staff central to vaccination education, the provision of resources to support the program, key partnerships and guidance on implementation and adoption of vaccination policies. CONCLUSION Adequate organizational commitment, resources, communication, training, and partnerships were the most critical facilitators for these countries to improve childhood vaccination.
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Affiliation(s)
- Cam Escoffery
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kyra A Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anna Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Katie Rodriguez
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chandni Jaishwal
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chenmua Yang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sameer Dixit
- Center for Molecular Dynamics Nepal, Kathmandu, Nepal
| | - Anindya Bose
- WHO Nepal Immunization Preventable Disease Division, Kathmandu, Nepal
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidemiologique Et de Formation (IRESSEF), Dakar, Senegal
| | - William Kilembe
- Center for Family, Health Research in Zambia, Lusaka, Zambia
| | | | - Matthew C Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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Sakas Z, Hester KA, Rodriguez K, Amos Diatta S, Ellis AS, Malick Gueye D, Matapano D, Souleymane Mboup P, Awino Ogutu E, Yang C, Bednarczyk RA, Freeman MC, Sarr M, Castillo Zunino F, Darwar R, Dounebaine B, Dudgeon MR, Escoffery C, Isett KR, Jaishwal C, James H, Keskinocak P, Pablo Montagnes B, Nazzali D, Orenstein W, Rueda Robayo M, Rosenblum S, Smalley HK. Critical success factors for high routine immunization performance: A case study of Senegal. Vaccine X 2023; 14:100296. [PMID: 37113739 PMCID: PMC10126928 DOI: 10.1016/j.jvacx.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/24/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023] Open
Abstract
Background The essential components of a vaccine delivery system are well-documented, but robust evidence is lacking on how policies and implementation strategies are operationalized to drive catalytic improvements in coverage. To address this gap, we identified success factors that supported improvements in routine immunization coverage in Senegal, especially from 2000 to 2019. Methods We identified Senegal as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health facility, and community-level, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Strong political will and prioritization of resources for immunization programming supported urgent allocation of funding and supplies; 2) Collaboration between the Ministry of Health and Social Action and external partners fostered innovation, capacity building, and efficiency; 3) Improved surveillance, monitoring, and evaluation allowed for timely and evidence-based decision making; 4) Community ownership of vaccine service delivery supported tailored programming and response to local needs; and 5) Community health workers spearheaded vaccine promotion and demand generation for vaccines. Conclusion The vaccination program in Senegal was supported by evidence-based decision making at the national-level, alignment of priorities between governmental entities and external partners, and strong community engagement initiatives that fostered local ownership of vaccine delivery and uptake. High routine immunization coverage was likely driven by prioritization of immunization programming, improved surveillance systems, a mature and reliable community health worker program, and tailored strategies for addressing geographical, social, and cultural barriers.
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Hester KA, Sakas Z, Ellis AS, Bose AS, Darwar R, Gautam J, Jaishwal C, James H, Keskinocak P, Nazzal D, Awino Ogutu E, Rodriguez K, Castillo Zunino F, Dixit S, Bednarczyk RA, Freeman MC. Critical success factors for high routine immunization performance: A case study of Nepal. Vaccine X 2022; 12:100214. [PMID: 36148265 PMCID: PMC9486040 DOI: 10.1016/j.jvacx.2022.100214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 07/14/2022] [Accepted: 08/31/2022] [Indexed: 12/04/2022] Open
Abstract
Nepal reported high and sustained immunization coverage compared to peers. National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building. Pro-vaccine messaging through various mediums, including Female Community Health Volunteers, which was tailored to local needs, generated public awareness. Cultural values fostered collective responsibility and community ownership of vaccine coverage.
Introduction The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019. Methods We identified Nepal as an exemplar in the delivery of early childhood immunization through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Codification of health as a human right, - along with other vaccine-specific legislation - ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage. Conclusion This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.
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Affiliation(s)
- Kyra A. Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anna S. Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anindya S. Bose
- World Health Organization, Nepal-Immunization Prevention Division, Nepal
| | - Roopa Darwar
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jhalak Gautam
- Family Welfare Division, Department of Health Services, Ministry of Health and Population, Nepal
| | - Chandni Jaishwal
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Hanleigh James
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Dima Nazzal
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | - Katie Rodriguez
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Francisco Castillo Zunino
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | - Matthew C. Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Corresponding author at: 1518 Clifton Road NE, Atlanta, GA 30322, USA.
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Sikder SS, Ghoshal R, Bhate-Deosthali P, Jaishwal C, Roy N. Mapping the health systems response to violence against women: key learnings from five LMIC settings (2015-2020). BMC Womens Health 2021; 21:360. [PMID: 34629077 PMCID: PMC8504083 DOI: 10.1186/s12905-021-01499-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022]
Abstract
Background Violence against women (VAW) is a global challenge, and the health sector is a key entry point for survivors to receive care. The World Health Organization adopted an earlier framework for health systems response to survivors. However, documentation on the programmatic rollout of health system response to violence against women is lacking in low and middle-income countries. This paper studies the programmatic roll out of the health systems response across select five low- and middle-income countries (LMIC) and identifies key learnings. Methods We selected five LMIC settings with recent or active programming on national-level health system response to VAW from 2015 to 2020. We synthesized publicly available data and program reports according to the components of the WHO Health Systems Framework. The countries selected are Bangladesh, Brazil, Nepal, Rwanda, and Sri Lanka. Results One-stop centers were found to be the dominant model of care located in hospitals in four countries. Each setting has implemented in-service training as key to addressing provider knowledge, attitudes and practice; however, significant gaps remain in addressing frequent staff turnover, provision of training at scale, and documentation of the impact of training. The health system protocols for VAW address sexual violence but do not uniformly include clinical and health policy responses for emotional or economic violence. Providing privacy to survivors within health facilities was a universal challenge. Conclusion Significant efforts have been made to address provider attitudes towards provision of care and to protocolize delivery of care to survivors, primarily through one-stop centers. Further improvements can be made in data collection on training impact on provider attitudes and practices, in provider identification of VAW survivors, and in prioritization of VAW within health system budgeting, staffing, and political priorities. Primary health facilities need to provide first-line support for survivors to avoid delays in response to all forms of VAW as well as for secondary prevention. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01499-8.
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Affiliation(s)
| | - Rakhi Ghoshal
- CARE India, No.14, Patliputra Colony, Patna, Bihar, 800013, India.,WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | | | - Chandni Jaishwal
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, NE, Atlanta, GA, 30322, USA
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institutet, 171 77, Stockholm, Sweden. .,The George Institute for Global Health, New Delhi, India.
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Anil OM, Yadav RS, Shrestha N, Koirala S, Shrestha S, Nikhil OM, Baidar M, Chaudhary N, Jaishwal C, Yadav NS, Mahara AB, Jha RK, Poudyal AK. Prevalence of Cardiovascular Risk Factors in Apparently Healthy Urban Adult Population of Kathmandu. J Nepal Health Res Counc 2019; 16:438-445. [PMID: 30739937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/21/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cardiovascular diseases account for most deaths and major proportion of disabilities worldwide. Major cardiovascular risk factors are implicated in almost 75% of cardiovascular diseases. There has been a rapid increase in prevalence of such risk factors in apparently healthy young adults of urban population. This study aimed to find prevalence of such risk factors in order to implement preventive strategies against cardiovascular diseases in our setting. METHODS A free heart camp was organized following wide dissemination of information through print, online, TV, radio and social media. Pretested data collection tool was used by trained enumerators using standard guidelines and calibrated devices. Demographic, anthropometric, physical examination and blood investigation data were obtained. Standard guidelines were followed to define and categorize the obtained information. Data was analyzed using SPSS V20. RESULTS A total of 5530 participants were enrolled after carefully applying inclusion and exclusion criteria. Mean age of study population was 38.14±13.03 years. There were 3298 (59.6%) males with mean age of 37.67±12.99 years and 2232 (40.4%) females with mean age of 38.84±13.05 years. Majority of study population (29.6%) belonged to 30-39 years age group. Prevalence of tobacco and alcohol consumption was 29.3%(95%CI:28.1-30.5) and 32.7%(95%CI:31.5-34.) respectively. Prevalence of inadequate fruits and vegetables intake, low physical activity and overweight or obesity was 75.4%(95%CI:74.3-76.6), 61.1%(95%CI:59.8-62.4) and 41.3%(95%CI:40.0-42.6) respectively. Prevalence of hypertension, diabetes and dyslipidemia was 26.4%(95%CI:25.3-27.6), 5.3%(95%CI:4.7-5.9) and 86.9%(95%CI:85.9-87.7) respectively. These results were statistically significant in both age and sex based distribution. CONCLUSIONS Prevalence of major cardiovascular risk factors in apparently healthy adult population of Kathmandu Valley was high. Dyslipidemia, unhealthy diet, physical inactivity and overweight or obesity were most prevalent cardiovascular risk factors.
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Affiliation(s)
| | - Randhir Sagar Yadav
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Nitesh Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Sachit Koirala
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Shumneva Shrestha
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | | | | | | | | | | | - Amod Kumar Poudyal
- Department of Community Medicine and Public Health, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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