Immunization delivery in the second year of life in Ghana: the need for a multi-faceted approach

Abstract

Introductionin 2012, pneumococcal conjugate vaccine (PCV), rotavirus vaccine and a second dose of measles-containing vaccine (MCV2) were introduced into the Expanded Program on Immunization (EPI) in Ghana. According to Ghana’s EPI schedule, PCV and rotavirus vaccine are given in the first year of life and MCV2 in the second year of life (2YL) at 18 months. Although coverage with the last doses of PCV and rotavirus vaccine reached almost 90% coverage within four years of introduction, MCV2 coverage did not rise above 70%. The World Health Organization Global Measles and Rubella Strategic Plan established a 2020 milestone to achieve at least 95% coverage with the first and second doses of measles-containing vaccine in each district and nationally. We developed a project to address challenges to delivery of immunizations and other child health services at the 18-month visit and throughout the 2YL.Methodsfrom March to April 2016, we conducted a cluster survey of households (HHs) with children 24-35 months of age in three regions in Ghana to assess knowledge, attitudes and beliefs among caregivers about immunization during the 2YL and to collect childhood vaccination history data using vaccination cards. Three independent samples were selected from the Northern (NR), Volta (VR), and Greater Accra (GAR) regions. A survey and direct observations were performed a ta representative sample of health facilities (HFs) providing immunization services in the same regions to further characterize barriers to immunization access, utilization and delivery in the 2YL.Resultsdata on a total of 464 children ages 24-35 months were collected in the HH survey: 211 in NR, 153 in VR, and 100 in GAR (response rate > 99%). First dose of measles-containing vaccine (MCV1) coverage was (NR: 87%, VR: 96%, GAR: 99%); however, MCV2 coverage was lower (NR: 60%, VR: 83%, GAR: 70%). MCV1 to MCV2 dropout was 32% in NR, 14% in VR, and 31% in GAR. Caregiver awareness of immunization against measles was 69% in NR, 75% in VR, and 68% in GAR yet less than half knew the recommended ages for receiving the vaccine, (NR: 4%, VR: 9%, GAR: 44%). Among 160 HFs participating in the survey (>50 in each region), most lacked a defaulter tracing system (NR: 94%,VR: 76%,GAR: 85%). A varying proportion of HCWs correctly indicated how to record a catch-up first dose of MCV administered to an 18-month-old child in the 12-23 month immunization register (NR: 38%, VR: 55%, GAR: 67%) and on the vaccination card (NR: 54%, VR: 53%, GAR: 76%). Although more than half of caregivers would accept text messages, (NR: 57%, VR: 78%, GAR: 96%) including reminders, related to their child’s immunizations, < 10% HFs were utilizing this practice.Conclusionchallenges encountered with the establishment of an immunization visit beyond the first year of life included knowledge gaps among caregivers, high dropout rates between MCV1 and MCV2 in all study regions, and a lack of defaulter tracing systems in most healthcare facilities providing childhood immunizations. Targeted strategies that pro...

Development of a valid and reliable scale to assess parents’ beliefs and attitudes about childhood vaccines and their association with vaccination uptake and delay in Ghana

“…To collect CVAS module data, we designed and implemented a cross-sectional, household-based survey in Northern Region, Ghana. The primary intent of the survey was to estimate regional vaccination coverage as part of a multi-partner initiative to improve the coverage of childhood vaccinations in Ghana and is detailed elsewhere [19]; we incorporated our CVAS module into this survey. For the survey, we randomly selected 37 enumeration areas by probability proportional to size (PPS) sampling and then aimed to randomly select 10 households with children aged 12–35 months within each enumeration area.…”

“…However, challenges are noted around the timeliness of vaccinations received, with up to 60% of infants receiving delayed vaccinations [18], leading to survey items about the determinants of vaccination delay in Ghana. Additionally, the country has experience challenges with reaching high vaccination coverage for vaccines provided to children in their second year of life [19], with a recent study noting the need to implemented targeted strategies promoting parental behavior change to strengthen coverage of all vaccines recommended in in Ghana, regardless of age. Another study of human papillomavirus (HPV) vaccination uptake in Ghana identified challenges with low perceived risk of disease, role of the parents (as opposed to the provider or government) as the primary decision-makers for vaccination of the child, and parental concern about side effects following vaccination.…”

“…Another study of human papillomavirus (HPV) vaccination uptake in Ghana identified challenges with low perceived risk of disease, role of the parents (as opposed to the provider or government) as the primary decision-makers for vaccination of the child, and parental concern about side effects following vaccination. As part of a multi-partner effort to further improve the Ghana immunization program, particularly for vaccines given beyond one year of age, Ghana Health Service (GHS) recognized the need to tailor its vaccine acceptance and demand promotion activities [19] to ensure both high and timely uptake of all vaccines. This initiative, detailed elsewhere [19], includes special efforts to catch children up on missed vaccines, increase timeliness of all recommended vaccinations, improve social mobilization efforts, tailor healthcare worker and caregiver interpersonal communications, and improve urban immunization strategies.…”

“…As part of a multi-partner effort to further improve the Ghana immunization program, particularly for vaccines given beyond one year of age, Ghana Health Service (GHS) recognized the need to tailor its vaccine acceptance and demand promotion activities [19] to ensure both high and timely uptake of all vaccines. This initiative, detailed elsewhere [19], includes special efforts to catch children up on missed vaccines, increase timeliness of all recommended vaccinations, improve social mobilization efforts, tailor healthcare worker and caregiver interpersonal communications, and improve urban immunization strategies. The vaccine acceptance scale construction effort was housed within this multi-partner effort, with specific programmatic objectives of informing the design of future vaccine acceptance and demand promotion activities and evaluating the effect of these activities.…”

Factors influencing the sustained utilization of child welfare services among children 18 to 59 months in a low-income rural community.

“…However, about 70% of districts and regions have challenges with effective coverage of childhood immunization and a majority of children under-5 do not fully receive components of the child welfare services including immunization and growth monitoring (Bonsu, Senaya, Yawson, & Eleeza, 2017). A study conducted in Techiman to evaluate the immunization coverage among children older than 12 months revealed that, about 80% of children between 12-23 months were immunized, however, it was revealed that most of these children were partially immunized and a small number of children were not immunized at all (Adokiya et al, 2017).Patronage of child welfare clinic services including immunization of children and regular growth monitoring of children in Ghana has remained low (Nyaku, Wardle, Ametewee, Bonsu, & Opare, 2017). Statistics from the Ghana Health Service shows a consistent decline in the Child Welfare Clinic attendance and this decline has been attributed to knowledge gaps among caregivers, and a lack of defaulter tracing systems in most child welfare clinics (GHS, 2014).…”