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Table 2 Key findings, categorised by study themes, encompassing SIREP and WHO program improvement priorities

From: Strengthening routine immunization in Papua New Guinea: a cross-sectional provincial assessment of front-line services

 Strengths in local systemsOpportunities for improvement in local systems
Local service planning and delivery
Data sources: interview and audit
• Recent innovations recognised by most (14/18) staff: new vaccines or planning, with one mention of new quarterly outreach increasing efficiency
• Recent in-service training in SIREP reported by many (11/18) staff
• Static services available 5 days per week
• All clinics tallied vaccinations to report into national health information system
• 82% of clinics conducted as planned (annual total of 109 implemented of 133 planned)
• Outreach was limited - minority (2/9) static facilities used outreach with overnight stays for remote areas
• Outreach planning process not able to be described by half the staff, less than a quarter planned on population basis, no clinics used population data to estimate outreach supply quantities
• Many clinics with few patients: mean 17/clinic, IQR 3–26, maximum = 62
• Estimation of coverage impossible for more than half (10/18) staff due to lack of catchment data, only one clinic displayed coverage
• No clinics with lists of children overdue for vaccination, one third of clinics used child registers
• Local reasons for clinic cancellation were adverse weather, lack of transport or slow disbursement of funds
Infrastructure and supplies
Data sources: interview, audit and observation
• Most clinics had road access, with two outreach clinics on walking trails
• Water supply in nine (of 12) clinics and electricity in eight (of 9) static sites
• Functional injection equipment, safety boxes and weight scales in all clinics
• 10 (of 12) clinics with appropriate, functioning cold chain equipment
• Supplies of all relevant vaccines (including IPV and PCV) and injection equipment present
• No expired or discontinued vaccines found
• Eight (of 12) clinic sites needed renovation (by local standards), 9 (of 12) did not have usable toilets
• No clinics with kits for managing severe acute adverse events
• Cold storage monitoring inconsistent, no clinics with written temperature records
• Half the clinics had clear records of vaccine stock usage, not well reconciled with tallies of patients vaccinated, none able to match supply to population
• Recording forms did not clearly account for three new vaccines: IPV, PCV, MR
• Lack of important guidance documents: one (of 12) had an immunization manual, and four had child health standard treatment guidelines
Staff knowledge and staff practice during immunization sessions
Data sources: interview and observation
• More than half of staff could correctly cite recently introduced vaccines (11/18) and handling of lyophilised multi-dose vials (15/18)
• Twenty staff (nurses and CHWs) across 12 clinics, vaccinating mean of 17 children per clinic falls below WHO maximums (30 per staff member [15]);
• Core interactions (weight, screening and vaccination) done for 14 of 15 observed patients
• Observation against WHO session checklist (Fig. 1) shows key elements of safe injection in over 80% sessions
• Less than half of staff could correctly cite immunization schedule (8/18), one national program target (3/18), storage temperature (6/18), interpret vaccine vial monitor display (3/18), or handling of liquid multi-dose vials (2/18)
• Some important functions omitted in patient flow observations: educational interactions observed for just two of 15 patients, preventive care for mother and AEFI monitoring observed in none
• Waiting times in 15 patient flow observations were significant: mean 51 min arrival to final interaction (IQR 13–90, maximum 210)
• Observation against WHO session checklist sessions shows gaps in preparatory checking of vaccines, client communication and AEFI observation, and (for less than 20%) in safe injection
Missed opportunities for vaccination
Data sources: interview, audit and observation
• Most staff (13/18) stated they would open a multi-dose vial for just one patient• Due vaccinations had been missed in 3 of 10 Child Health Record books
• Reasons for missing vaccination included vaccine out of stock, clinic visit not for purpose of vaccination, or (for birth doses) childbirth in community
• Two (of 15) observed patients asked to return another day for vaccination
• Thirteen (of 17 respondents) staff stated they would usually ask a sick child to return at another time for vaccination
Integration of other services
Data source: interview and
observation
• All staff noted a policy of integrating other care and vaccination
• Nine (of 18) staff cited at least one other care (usually childhood illness) regularly integrated
• Child illness care available in nine (of 12) clinics
• Child illness care accompanied vaccination in seven (of 15) observed patients
• Weight measured in all observed patients
• Four (of 18) staff mentioned maternal health service as integration option
• Three clinics (of 12) lacked supplies, or service organization, to integrate childhood illness care with vaccination
• No observation of catch-up vaccination with children presenting for illness
• Three (of 15) patients observed to receive feeding counselling, two to receive vitamin A, 1 to receive albendazole
• No observations of maternal preventive care or counselling
• Staff reported insufficient numbers as main constraint on integrated care
Community engagement and family viewpoints
Data sources: interview, observation and focus group discussion
• Three (of 12) clinics provided verbal group health education alongside vaccination sessions
• Three (of 18) staff reported support (for example food) provided by local communities
• No fees for vaccines reported or observed and families did not report fees as barrier to vaccination
• No reported use of community-based trained lay health workers to help with organization, mobilization or education.
• Six (of 12) clinics charged small administrative fees
• Many families (6/10 groups) cited travel time, and transport costs, as significant constraints on timely attendance for vaccination
• Many families (6/10 groups) sought more mobile clinics, more “on-demand” vaccination, and more reliable clinic timing
• Some families (4/10 groups) sought more respectful staff-client interactions
• No male family members were observed in attendance, staff cited embarrassment as a constraint on male involvement
  1. Notes: SIREP Special Integrated Routine EPI Strengthening Program, IPV Inactivated polio virus vaccine, PCV Pneumococcal vaccine, MR Measles-rubella combination vaccine, IQR Interquartile range