a comprehensive assessment of the quality of immunization services in one major area of dhaka city,...

Tropical Medicine and International Health

volume 3 no 12 pp 981–992 december 1998

A comprehensive assessment of the quality of immunizationservices in one major area of Dhaka City, Bangladesh

Henry Perry1,2, Robert Weierbach3, Shams El-Arifeen1 and Iqbal Hossain3

1 MCH-FP Extension Project (Urban), ICDDR,B, Dhaka, Bangladesh

2 Johns Hopkins School of Hygiene and Public Health, Department of International Health, Baltimore, USA

3 BASICS (Basic Support for Institutionalizing Child Survival) Project, Dhaka, Bangladesh

Summary This report assesses the quality of service inputs, service processes and service outcomes (with the exception

of coverage and effectiveness) for immunization services in Zone 3 of Dhaka City. The results indicate that in

general, the providers of immunization services are knowledgeable, friendly and give technically appropriate

immunizations. Client ratings of the quality of services are quite good. Access is 90% for childhood

immunizations and 89% for tetanus toxoid (TT) immunizations for women with a child , 1 year old. Three

areas were identified as needing attention: frequently missed opportunities for the promotion or provision of

immunizations; uneven distribution and utilization of immunization sites, and some fundamental

weaknesses of the TT immunization programme (lack of awareness among women of reproductive age

about the importance of TT immunization, low access to it among women of reproductive age who do not

have a child , 1 year of age, and confusion among women and service providers about the purpose of TT

immunization and the dosage schedule). Efforts to monitor and strengthen the quality of EPI activities will

facilitate further decline in the numers of deaths and illnesses from vaccine-preventable diseases. The

approaches used in this study and the typology for quality assessment are widely applicable elsewhere.

keywords immunization programmes, quality, Bangladesh, urban

correspondence Dr Henry Perry, BASICS/Bangladesh, Road 23, House 1, Gulshan 1, Dhaka 1212,

Bangladesh. E-mail: [email protected]

Introduction

Although interest in quality assurance activities related to

primary health care in developing countries has been growing

recently (Nicholas et al. 1991), only a small number of studies

have been published (Reerink & Sauerborn 1996). In general,

Expanded Programme on Immunization (EPI) evaluations

have focused on population coverage, and there has been less

effort given to assessing the quality of immunization service

provision. In spite of the growing importance of urban EPI

activities in developing countries, one recent comprehensive

review identified no published studies concerning the quality

of immunization services from the viewpoint of health

worker behaviour, organization of services, or client

satisfaction (Atkinson & Cheyne 1994). One assessment of

EPI services in an urban area of Guinea identified as key

quality problems the lack of knowledge among mothers

about how many immunizations their child should receive

and by what age, long waiting times, high fees for vaccin-

ations, missed opportunities for immunization, poor rapport

with health workers and occurrence of abscesses after

vaccination (Cutts et al. 1990).

During the past decade, Bangladesh has made remarkable

progress in improving its overall coverage of childhood

immunizations and maternal tetanus toxoid (TT)

immunizations in both rural and urban areas (Huq 1991; Hill

et al. 1993). As recently as the mid-1980s, the national

coverage level for childhood immunizations and maternal TT

immunizations were both only 2% (WHO 1995), but by the

mid-1990s, the childhood coverage for all antigens had

reached 76% and maternal TT coverage, 86% (EPI 1995a).

Although the country’s EPI programme was established in

1979, it did not become fully operational until 1985, and a

specific focus on urban EPI activities did not begin until 1989.

Within Dhaka City proper, access to childhood immunization

services (as measured by BCG immunization coverage)

reached 92% in 1995, and the percentage of fully immunized

12–23-month-old children was 59%. TT coverage among

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Tropical Medicine and International Health volume 3 no 12 pp 981–992 decemer 1998

H. Perry et al. Quality of immunization services in urban Bangladesh

women with a child under 1 years reached 84% during the

same year (Roy 1995). The success of Bangladesh’s national

EPI programme has been one important reason for the

continuing decline of under-five mortality during the past

decade (NIPORT et al. 1997).

In spite of these remarkable achievements, recent data

indicate that 17% of the deaths of under-fives in Bangladesh

are due to 3 vaccine-preventable diseases: neonatal tetanus,

measles and whooping cough (MHFW 1995). Current

estimates indicate that measles and tetanus are each respons-

ible for 20 000 deaths per year in Bangladesh (D.H. Sniadack,

personal communication). In the urban slums, neonatal tet-

anus and measles cause 19% and 5% of infant deaths,

respectively, and measles cause 16% of the deaths of 1–4-

year-old children (Baqui et al. 1993). Since immunization is

one of the most cost-effective approaches to mortality

reduction in children (Foster et al. 1993; Steinglass et al. 1993;

World Bank 1993), there is every reason to continue efforts in

Bangladesh to reduce the number of deaths, long-term

disabilities, and acute illnesses caused by diseases which are

vaccine-preventable.

In 1995, approximately 25 million people were living in the

urban areas of Bangladesh, comprising 21% of the total

population (BBS 1994, 1995). While the growth rate for the

country as a whole is about 2% per year, the annual growth

rate of urban areas is 6% (Islam 1990). The population of

Dhaka City has grown from 1.7 million in 1974 to 3.4 million

in 1981 to 6.8 million in 1991 (BBS 1994), and by the year 2015

its population is projected to be 18.5 million, which would

make it the ninth largest city in the world (UNFPA 1996).

Over the next 2 decades, the urban population of Bangladesh

is expected to double to approximately 50 million people (BBS

1991; UNICEF 1993). Maintaining a high-quality EPI in the

face of such rapid growth is important for minimizing the

unnecessary burden of morbidity and mortality from vaccine-

preventable diseases in the urban areas.

Our report provides an overview of the findings related to

the quality of EPI services in Zone 3 of the Dhaka City

Corporation obtained during a 1994 comprehensive Needs

Assessment Study of maternal and child health and family

planning (MCH-FP) services. Recommendations for the

improvement of the quality of EPI services in Zone 3 and

implications for the national EPI policy and the relevance of

the findings for immunization programmes in other

developing countries are discussed.

Conceptual framework

Two paradigms for quality assurance of health and family

planning services in developing countries have been

consolidated for our analysis, namely that of Bruce (1990) for

family planning and that of the Quality Assurance Project

(Brown et al. 1992; Franco et al. 1993) for child survival

services. According to the conceptual framework described in

Table 1, a comprehensive assessment of the quality of

immunization services involves assessing the quality of

service inputs, service processes, and service outcomes. This

report analyses all of the dimensions of quality shown in

Table 1 except for coverage and effectiveness. Analyses of the

coverage of immunization services in Zone 3 were reported

elsewhere (Perry et al. 1997; 1998a,b).

The comprehensive framework for quality assessment of

immunization services developed here takes a systematic view

of the entire sequence of service inputs, service processes and

service outputs. This framework does not attempt to deline-

ate the causal relationships between service characteristics

© 1998 Blackwell Science Ltd982

Table 1 Conceptual framework for assessment of the quality of immunization services

Assessment of service inputs Assessment of service processes Assessment of service outputs

Facilities Constellation of services Client satisfaction

Equipment and supplies Technical quality (of services) Client perception of quality

Training and experience Counseling quality (including missed Client knowledge (about the purpose of vaccinations,

of MCH-FP providers opportunities for promoting or location of immunization sites, and timing of the

providing immunizations) next dose)

Immunization knowledge possessed Quality of interpersonal relations Client attitudes (about the importance of immunizations

by MCH-FP providers and about plans for additional vaccinations)

Attitudes among MCH-FP providers Access Client behaviour (regarding previous immunization

(about the adequacy of training) activities)

Supervision Safety Efficiency (in the provision of immunization services)

Amenities Promotion of continuity of care Coverage (of immunization services within the targeted

population)*

Effectiveness*

*not assessed in the current study

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Tropical Medicine and International Health volume 3 no 12 pp 981–992 december 1998


and the relative importance of each characteristic for the

quality of the overall immunization programme. We used this

framework to assess the quality of services provided by all the

clinics providing immunization services – both governmental

and nongovernmental – in a major urban area of a develop-

ing country. Because of the broad scope of this assessment, a

rigorous analysis of each service characteristic with com-

parisons to predetermined standards at each of the service

delivery sites was not possible. What follows, then, is a

description of the findings with an attempt to specify the

major issues facing the delivery of immunization services in

this area of Dhaka City.

Materials and methods

During the second half of 1994, the MCH-FP Extension

Project (Urban) of ICDDR,B, in cooperation with the

Government of Bangladesh, Dhaka City Corporation (DCC),

and Concerned Women for Family Planning (CWFP), a

national nongovernmental organization (NGO), conducted a

comprehensive Needs Assessment Study concerning the

MCH-FP services in Zone 3, including immunizations. Other

findings from this study were reported elsewhere (Arifeen &

Mookherji 1995; Mookherji et al. 1996; Perry et al. 1996a).

Zone 3 is one of 10 Zones of the Dhaka City Corporation

(DCC located in the south-western section of the city

alongside the Buriganga River. It has a population of

approximately 450 000. Zone 3 has a similar number of

immunization sites per capita as the other Zones of DCC and

is generally similar to them in terms of socioeconomic

characteristics. Most of the data included in this report were

collected at the time of the 1994 Needs Assessment Study.

Approaches used for gathering information for the Needs

Assessment Study included:

d a baseline survey of 5940 Zone 3 households;

d an inventory of the 36 MCH-FP clinics in Zone 3 (EPI

Centres, MCH clinics, family planning clinics,

dispensaries, and satellite clinics);

d observations of 165 client–provider interactions at

clinics and at the time of home visits from 57

fieldworkers;

d interviews with 33 MCH-FP clinic providers;

d interviews with 165 MCH-FP clinic clients;

d interviews with 57 MCH-FP fieldworkers;

d interviews with 114 clients of fieldworkers.

Fieldworkers are community-based and visit the homes of

women of reproductive age every two months primarily to

promote family planning. 30 000 fieldworkers (called Family

Welfare Assistants) are employed by the Family Planning

Directorate of the Ministry of Health and by NGOs (Mitra

et al. 1994). In addition, 16 000 male Health Assistants are

employed by the Health Directorate of the Ministry of

Health to visit homes in rural areas to promote

immunizations and other health-related activities (Phillips et

al. 1996).

All data were collected by staff of the MCH-FP Extension

Project (Urban) and processed by the data management

section of the project. The baseline household survey covered

all households in 160 randomly selected clusters from

throughout Zone 3, including 100 non-slum clusters and 60

slum clusters. They were selected using a multistage areal

sampling methodology in which geographical areas were also

characterized as predominantly slum and predominantly

nonslum. The findings from the survey have been weighted

since the sampling probabilities varied from one stratum to

another. At each of the 36 MCH-FP clinics in Zone 3, at least

one provider was interviewed and a detailed inspection made

of the clinic. Since several providers staffed more than one

clinic, we interviewed 33 providers for the study.

In 12 of the 14 clinics offering immunizations, at least four

encounters between a health care provider and a client were

observed. At two clinics, the small number of patients

prohibited inclusion of the full complement of four

encounters within the time available to the observers. 165

client–provider interactions were observed and, at the time

the client was leaving the clinic, she was also interviewed

separately.

Each of 57 fieldworkers who provide MCH-FP services at

the doorstep to married women of reproductive age in Zone 3

were also interviewed. A field researcher accompanied each

fieldworker during a typical day of home visitation activities.

The fieldworker was not informed in advance that a field

researcher would be accompanying her. During that day of

observation, the researcher recorded the details of two

encounters for each fieldworker. Later during the same day,

the researcher returned to the home of the client to interview

her separately.

In addition to data from the Needs Assessment Study, data

from the July September 1995 round of the Urban Panel

Survey were also included. The Urban Panel Survey collects

health and demographic information on a quarterly basis

from the same cluster of households included in the baseline

survey.

Statistical significance was determined by x2 tests for

differences in distribution of characteristics between groups.

If x2 test results were calculated for a two-by-two table, the

Yates continuity correction was used. When the expected

value for such a table was , 5, Fisher’s exact two-tailed test

was employed. Data was analysed with EPI INFO version

6.02 and SPSS for Windows version 6.0 statistical software.


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Results

Assessments of service inputs

In Zone 3, 14 of the 36 MCH-FP clinics giving at least one

type of MCH-FP service to ambulatory clients provide

immunization services. These 14 clinics comprise 9 DCC EPI

Centres, 4 CWFP clinics, and a Ministry of Health and

Family Welfare maternity centre. Household survey

respondents who had obtained an immunization during the

previous 6 months were asked where they had done so (Table

2). The use of private physicians, private clinics or health

facilities outside of Zone 3 for immunization services was

infrequent.

The DCC EPI Centres are by far the most frequently used

type of health facility for childhood immunizations in Zone 3

(Table 3), and the Azimpur Maternity Centre provides most

maternal TT immunizations. Table 3 shows that 77% of

childhood immunizations and 68% of maternal TT

immunizations in Zone 3 are obtained at government clinics.

Clinic staff reported that problems in the supply of vaccine

were rarely encountered. Each site had a steam sterilizer and

an adequate supply of immunization supplies and cold-chain

equipment.

At each of the 13 clinics giving immunizations, the worker

who was interviewed provides immunizations. All but 1 of

the 13 indicated that they had received training about

immunizations and all but 3 indicated that they had received

on-the-job training on immunizations as well. On average,

each of the 13 providers had 16.1 years of experience in

working with their respective organizations.

The knowledge of providers regarding the official

immunization schedule recommended by the Ministry of

Health was assessed and found to be satisfactory overall. Of

the 20 staff members who participated in the Needs

Assessment Study who do not administer immunizations,

75% or more were able to recall the Ministry of Health’s

recommended schedules for BCG, DPT and measles

immunizations, but only 15–20% were able to recall the

recommended schedule for either polio or maternal TT. Most

of these staff did not know that an OPV dose should be given


Table 2 Sources of child and maternal immunizations during the previous 6 months 1994. Percentage of clients obtaining service (weighted)

Child immunization Maternal tetanus immunization

–––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––

Slum Non–slum Total Slum Non–slum Total

Location (n 5 451) (n 5 614) (n 5 1065) (n 5 70) (n 5 163) (n 5 233)

Zone 3 clinic 086 083 085 080 060 068

Clinic or health centre outside Zone 3 014 014 014 014 019 017

Private physician or private clinic 000 004 002 006 021 015

Total 100 100 100 100 100 100

Note: The slum/nonslum percentage distribution for source of maternal tetanus immunization is statistically significant (P , 0.01)

Table 3 Specific source of child and maternal immunizations during previous 6 months 1994

Percentage of total childhood Percentage of total maternal TT

immunizations obtained immunizations obtained

by Zone 3 clients by Zone 3 clients

Location (n 5 1065) (n 5 226)

Dhaka City Corporation EPI Centres 048 014

Azimpur Maternity Centre 012 040

Concerned Women for Family Planning Clinics 013 004

Zone 3 government clinic (dispensary or family planning clinic) 007 004

Other NGOs in Zone 3 005 001

Private physician or private clinic 002 016

Clinic outside of Zone 3 (but in Dhaka City) 007 008

Other (hospital, family planning clinic, clinic outside of Dhaka City, 012 012

private clinic, pharmacist, compounder)

Total 100 100

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along with the measles immunization. There also appeared to

be confusion regarding the TT dose schedule since, the policy

of the government for maternal TT immunizations had

recently changed from 2 doses during pregnancy to a lifetime

total of 5 doses.

The 57 fieldworkers are primarily family planning workers

who also promote immunizations and other basic MCH

services. On average they visit 21 families per day (Perry et al.

1996a) and come into contact with large numbers of mothers

and children. They were asked about their knowledge of the

schedule of immunizations. Sixty-eight percent (39/57) gave a

correct answer for the complete childhood schedule (BCG,

DPT, polio, and measles), and 82% were able to give the

correct dosage and schedule for maternal TT immunization.

The criteria used for assessing the fieldworkers’ knowledge of

the TT schedule were the same as those used with MCH-FP

providers in the clinics. In general, clinic staff are aware that

the purpose of TT immunization is to prevent neonatal

tetanus. However, there was a general misconception among

fieldworkers that the main effect of TT immunization is to

prevent tetanus in pregnant women.

Providers were asked if they felt that in general their

training was adequate for their current duties and in what

particular areas they felt a need for additional training. In

general they did not feel that they needed additional training

in immunizations. All 13 interviewed clinic staff who give

immunizations reported that a supervisor visited regularly. At

all 9 DCC EPI Centres the supervisor observed service

delivery practices. Clinic staff reported that supervisors rarely

made any suggestions for improvement, rarely offered praise

for good work and rarely reprimanded them for

unsatisfactory work.

All sites have enough seats for their usual client loads and a

waiting area protected from both rain and sun. All but 2 of

the regular immunization sites have functioning toilets. All of

the busier immunization sites have a system for ensuring that

clients are seen on a ‘first-come, first-served’ basis. Only 4 of

the 14 immunization sites have a separate examining room or

a separate area for counselling and consultation which is

curtained off. Most clinics had signs outside announcing that

immunizations are provided there. A poster promoting

immunization activities was visible in only half (7/14) of the

clinics which do providing immunizations and in only 18%

(4/22) of the clinics which do not.

Assessment of service processes

Both childhood immunizations and maternal TT immuniz-

ations are provided at each of the 14 immunization sites in

Zone 3. The DCC EPI Centres provide only immunizations.

One day a week, however, the members of the staff are

supposed to carry out home visits to encourage clients to

come to their clinic for immunization. The CWFP clinics and

the Azimpur Maternity Centre provide a wide range of

maternal and child health activities as well as family planning

services in addition to immunization services.

During 108 of 165 observed encounters between MCH-FP

clinic staff and their clients, the client had a child with her. In

33 instances the child received an immunization. Thirty-one

children were brought specifically for an immunization and

all 31 were immunized. Two children, who were brought due

to illness, also received an immunization during that visit. All

mothers of the 33 children had a child immunization card at

the time of leaving the clinic.

The Needs Assessment Study also included observations of

13 clinic encounters in which the client received a maternal

TT immunization. All 13 clients were pregnant, had come

specifically for a TT immunization and possessed a client TT

card at the time of leaving. Although five attended a clinic

offering other prenatal services, almost none were provided.

Only 1 of the 13 pregnant women receiving a TT immuniz-

ation was referred for prenatal care. Observations of 33

fieldworkers’ interactions with mothers who had a child , 1

year old revealed that the fieldworker reviewed the child’s EPI

card or discussed the importance of immunizations in only

55% of cases. In 6 of 7 observed encounters with clients who

were newly pregnant, the fieldworker discussed the

importance of TT immunization.

As part of the Zone 3 household survey, clients were asked

to show the interviewer their immunization card. Of 1374

women interviewed who had a child , 2 years, 61% had an

immunization card for the child. Of 4694 married women of

reproductive age interviewed who had ever been pregnant,

only 9% carried a maternal TT card, as did only 23% of the

707 women with a child aged less than 1 year old.

At the time of this study, there was no ongoing routine

monitoring of immunization coverage levels, of measles

outbreaks or of vaccine-preventable deaths in Zone 3. The 57

fieldworkers there (most of whom are employed by CWFP)

collect information on childhood deaths at the time of

routine home visits, but this is not routinely analysed nor is it

passed on to government health authorities for follow-up

investigation.

Field researchers observed the administration of the

immunization for all 33 children who were vaccinated. Vials

of vaccine were kept on ice during the session at each of the

12 clinics where the 33 children were immunized. Only 48%

(16/33) of the mothers were informed about potential side-

effects, however. Sterilization of equipment and the main-

tenance of sterility were observed at all vaccination sites and

deemed adequate.

MCH-FP providers in the clinics did not check the

immunization status of 65 (89%) children of mothers coming

for a reason other than immunization. Of the 6 children


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whose immunization status was checked, 3 were in need of

vaccination, and 2 of these children received an immunization

at the time of the clinic visit. The immunization status of

only 5 of the 10 children , 1 year old who were brought to an

immunizing MCH-FP clinic for other reasons was checked.

Assuming that the need for additional immunizations of

the 65 ‘unchecked’ children is similar to that for other

children aged 12–23 months in Zone 3 (the overall

immunization coverage among 12–23-month-old children in

Zone 3 is 51%) (Perry et al. 1998a), the incidence of missed

opportunities for immunization promotion is 44% among the

children coming to an MCH-FP clinic for some reason other

than immunization. During 45% of observed home visits the

fieldworkers failed to check the immunization status of

children , 1 year old. The provider failed to inquire about a

client’s TT immunization status in 99% of the cases in which

a woman came to an MCH-FP clinic for some reason other

than for a TT immunization. Since according to household

survey data, only 11% of women in Zone 3 have obtained all

recommended 5 TT immunizations, this suggests a missed

promotional opportunity incidence of 87%. In 6 of 7 ob-

served home visits in which the fieldworker identified a new

pregnancy, the worker discussed the importance of TT

immunization. In only 3% of the additional 107 observed

fieldworker–client interactions did the fieldworker review the

client’s TT immunization status and advise the client to

obtain TT vaccination.

Overall, 93% (43/46) of the immunization clients

participating in the Needs Assessment Study rated the clinics

as friendly, and, in 78% (36/46) of the encounters of

immunization clients with providers, the researcher thought

that the provider gave the client a ‘respectful and/or friendly

greeting.’ The researcher judged that in 91% (42/46) of these

encounters, the provider responded adequately to the client’s

questions. All 46 immunization clients said that they could

understand the staff member when he/she was ‘explaining

things’ to them, and 83% (38/46) of the immunization clients

said that they received ‘enough’ explanation ‘for their liking.’

Immunization sites in Zone 3 are not evenly distributed

and tend to be located in closely situated pairs, with a much

less frequently utilized site located within 0.5 km of a busy

site (Perry et al. 1996b). Unfortunately EPI sites are not

located in slum settings and poorer households tend to be

further away from EPI sites than better-off households: the

correlation coefficient between distance from the household

to the nearest EPI site with a socioeconomic index based on

quality of housing and household possessions is 2 0.19 (P ,

0.001). In the interviews with 46 clients who came to a clinic

for an immunization, 88% said that they had come to the

closest clinic which provides similar services near their home.

None of the clinics reported that clients are required to pay

for immunization services. However, 39% of the 46 clinic

clients in the Needs Assessment Study who obtained an

immunization at the time of a visit reported that they paid

something for the services they received.

None of the immunization clinics are open every day, and

only 1 is open 6 days a week. The 9 DCC EPI Centres provide

immunizations 5 days a week, while the CWFP clinics do so

only 1 day a week. All clinics open in the morning and close

in the early afternoon. For immunization programmes, a

crude general indicator of access is the percentage of the

target population obtaining at least 1 immunization.

According to this definition, access to immunization services

in Zone 3 is favourable. Seventy-three percent (482/660) of

children aged 0–11 months had obtained a BCG

immunization, and 90% of the 1374 children aged 0–23

months had received at least 1 vaccination. Eighty-nine

percent (629/707) of mothers with a child , 1year old had

obtained at least 1 TT immunization, and 68% of the 4694

married women of reproductive age who had ever been

pregnant had received at least 1 TT dose in the past. Access

to BCG among 0–11-month-old children is significantly lower

(P , 0.001) for children living in slum households (68%)

compared to children in nonslum households (81%). Also,

access to at least 1 TT immunization among mothers of

young children is significantly (P , 0.001) lower in slum than

in nonslum households (84 vs. 97%).

Proper sterilization procedures were being followed at the 8

clinic sites where they were observed. Procedures for disposal

of those needles and syringes which were no longer usable or

on precautions against injuries produced by used needles

were not observed.

In every observed interaction in which a child received an

immunization and a follow-up immunization was indicated

(n 5 30), the provider told the client when to return. Upon

leaving the clinic only 1 mother said that she did not know

when to return for the next immunization. During 12 of the

13 encounters in which a woman received a TT immuniz-

ation, the provider told the client when to return, and only 1

woman said that she did not know when to return for her

next TT immunization when she left.

Assessment of service outcomes

All immunization clients who participated in the Needs

Assessment Study were asked, ‘Do you feel that you received

the services that you wanted during today’s consultation?’

Ninety-eight percent (45/46) of the clients responded ‘yes’

and were presumably therefore satisfied with their service.

Ninety-six percent (44/46) said that they would recommend

the clinic where they received the immunization to a friend

for a similar service.

The 33 clinic clients whose child was vaccinated and the 66

clients of fieldworkers with a child under 5 years who had


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previously taken their child for at least 1 immunization were

asked why vaccinations are given (Table 4). Over half of the

respondents mentioned the prevention of a disease which is,

in fact, not vaccine-preventable. The most commonly

mentioned vaccine-preventable disease was measles, but only

one-third of the respondents knew this.

The 13 women receiving a TT immunization at the time

of a clinic visit and the 111 women visited by a fieldworker

who had previously been vaccinated against TT were asked

what the reasons for receiving a TT immunization are

(Table 5). Only two-thirds spontaneously mentioned the

prevention of neonatal tetanus. Only 57% of the

fieldworkers’ clients who had obtained a TT immunization

in the past knew this, and one-quarter did not know the

purpose of TT immunization.

Ten children , 1 year old attended a clinic offering

childhood immunizations but were not vaccinated at the time

of that visit. However, we do not know whether the children

were in need of vaccination. Twenty percent of the mothers

did not know that childhood immunizations were offered at

the clinic. Of the 74 women who attended a clinic where TT

vaccinations are provided but who did not obtain one, 23%

did not know that they were available there. Of the 73 clinic

clients participating in the Needs Assessment Study who

brought a child with them and who did not receive a vaccin-

ation, 64% were not planning to have their child vaccinated

in the future. Of these 47 women 66% said the child had

completed all of its doses. However, another 28% said the

child was older than 12 months and therefore ineligible for

immunization. The 152 clinic clients not receiving TT

immunization were asked about their immunization status

and their plans for TT vaccination. Sixty percent (91/152)

indicated that they intended to obtain another TT

immunization in the future. The most common reason cited

by the other 61 women was that they did not expect to

become pregnant again (cited by 53% of the 61 women).

Another 30% (18/61) said that they had obtained all the

necessary doses, although only 17% had actually done so and

only 50% had obtained at least 2 immunizations. Of the 91

clinic clients who planned to obtain a TT immunization later,

56% wanted to get it at the time of the next pregnancy.

The most common reason given by the 1179 ever-pregnant

women of reproductive age participating in the Urban Panel

Survey for never never obtaining TT immunization was lack

of information about the importance of TT immunizations

(Table 6). This answer was given by almost half of the

respondents. Women aged 30 years or younger were much

more likely to cite fear of a TT injection during pregnancy

(22 vs. 8%) than older women. Although lack of information

was cited by younger women and less frequently than by

older women, it was still the leading reason given by them.

Eighty percent of the 73 clinic clients who brought a child

with them said the child had received at least 1 vaccination

previously, and 78% of the 165 clinic clients said they had

received at least 1 TT immunization previously.

A wide range in the number of immunization clients was

seen at each of the 14 sites, ranging from 843 clients per

month at the busiest site to 49 clients at the least busy. The

number of immunization sessions given each month at each

site also varied widely; the average number of immunization

clients per session ranged from 3 to 146, with a median of 27

and an interquartile range of 8–49. The average number of

clients per worker per immunization session at the 13

immunization sites ranged from 3 to 73. The median number

was 18, and the interquartile range was 9–25.


Table 4 Reasons given by mothers for immunizing their child*

Percentage of mothers

Reason (n 5 99)†

Prevent measles 35

Prevent tuberculosis 30

Prevent tetanus 25

Prevent polio 19

Prevent diphtheria 16

Prevent whooping cough 04

Prevent diseases which mothers erroneously

think are amenable to immunization‡ 54

*Responses were unprompted. † More than 1 response was possible,

hence the total is greater than 100%; these 99 mothers include 33

women who brought their child for immunization at a clinic and 66

mothers who had an immunized child at the time of a home visit

from a fieldworker. ‡Among those diseases which mothers thought

were prevented by immunization were pneumonia, diarrhoea,

malnutrition, cancer, obstructed labour, and neonatal death from all

causes.

Table 5 Reasons given by immunized clients for receiving a tetanus

immunization

Percentage of women

who had previously

received a TT

immunization*

Reason (n 5 124)

Prevent child from developing tetanus 57

Prevent mother from developing tetanus 72

Other/don’t know 23

*These 124 women include 111 visited by a fieldworker who had

previously received a TT immunization as well as 13 women coming

to a clinic for TT immunization. Column percentages exceed 100%

because multiple responses were possible.

981-992 TMIH333 15/12/98 12:24 pm Page 987



Discussion

This study describes a comprehensive assessment of the

quality of immunization services in a major urban area of a

developing country. It exemplifies a methodology which can

be applied in developed or developing countries and in rural

as well as urban settings. The small sample size of clinics,

providers, and immunization clients and the cross-sectional

nature of the data collection prohibit any statistical analysis

of the causal relationships between quality of service inputs,

service processes and service outcomes. In our view the most

feasible approach to interpreting these findings is to specify

the characteristics of service inputs, processes and outcomes

which appear to have particularly high quality and those

which appear to need strengthening. Thus those aspects of

the immunization programme which require improvement

can be monitored. The methodology of quality assessment

and the approach to quality improvement described here is

particularly relevant to immunization programmes in settings

beyond Dhaka.

A number of aspects of immunization services in Zone 3

appear to be of high quality. By and large, the facilities,

equipment, vaccines, and other supplies are adequate. This is

no small feat in a country with such limited resources and

such a large population. The health workers in Zone 3 seem

to be well-trained and experienced. Sterilization procedures

are being followed and cold chain requirements are being met.

Immunization clients rated the friendliness and the

communication skills of the clinic staff as quite good: quality

of service and instructions on the need for follow-up appear

to be satisfactory. The competence and professionalism of

government vaccinators in Dhaka has previously been found

to compare favourably with that of other government health

workers (Blanchet 1989). Our findings suggest that both

government and nongovernment vaccinators are competent

and interact in a professional manner with their clients.

Overall access to immunization services for children and

mothers with a child under 12 months, defined as the

percentage of the target population with at least 1

immunization, is good.

Three areas need to be improved: the high frequency of

missed opportunities for the promotion or provision of

immunizations; the uneven distribution and utilization of

immunization sites; the low level of awareness among women

of reproductive age about the importance of TT immuniz-

ation, the low rate of access to it for women without a child

under 12 months, and the limited knowledge of women and

health workers about the purpose and dosage schedule of TT

immunization. Coverage levels for childhood immunizations

are particularly low in slum households (Perry et al. 1997;

1998a,b).

The rate of missed opportunities for promoting or

providing immunizations is quite high in both clinic and

domiciliary settings, and must decrease. EPI sites tend to be

clustered in pairs in Zone 3 and therefore are not situated to

promote optimal accessibility. They also tend to be further

away from slum households, which have lower immunization

coverage, than from nonslum households. The average

number of immunization clients per vaccinator per session

varies widely, and almost half of the immunization sites

provide services to fewer than 10 clients per vaccinator per

session. Personnel and services need to be redistributed for

better access and to make staff members more productive.

This will require improvements in the coordination of EPI

services. As a result of the formation of Zonal Coordination

Committees by the Dhaka City Health Department with the

assistance of the MCH-FP Extension Project (Urban) at

ICDDR,B, some of these problems are now being addressed.

One-third of the ever-pregnant women of reproductive age

in Zone 3 had never had a TT immunization, and three-


Table 6 Reasons given by ever-pregnant women of reproductive age for never having obtained a TT immunization

Percentage of respondents (weighted)

––––––––––––––––––––––––––––––––––––––––––––

Age # 30 years Age . 30 years Total

Reason (n 5 384) (n 5 840) (n 5 1224)

Lack of information about the importance of TT immunizations* 038 053 046

Feels there is no need 021 028 027

Afraid of TT (during pregnancy) 022 008 013

Does not know where to go 005 002 003

No specific reason/doesn’t remember/other 014 009 010

Total† 100 100 100

*includes the following responses: (1) does not know whether or when TT immunization is necessary, (2) does not know about TT

immunization/no information. †The distribution of responses between the 2 age groups differs significantly (P , 0.001).

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quarters of these women indicated that they were not aware

of its importance. One important reason was fear of being

vaccinated during pregnancy. Although TT immunizations

are currently given mainly to pregnant women, neither

routine prenatal care nor referrals to it are provided at the

time of TT immunization. Many fieldworkers and clients in

Zone 3 do not understand that the main purpose of maternal

TT immunization is to prevent tetanus of the newborn (EPI

1991). Confusion among the service providers about who

should receive a TT immunization may be due to a change of

the national policy just before these data were collected. In

the mid-80s, only pregnant women were to be given TT

vaccinations. More recently, however, all women of

reproductive age have been designated as the target group for

TT immunization, and the current policy – which needs

urgently to be implemented – is for women to obtain 5 doses

to achieve lifetime immunity.

The limited opening hours (all closed during late afternoon

and evening, one-third closed on Saturdays) may prevent

working mothers from using their services. Not all immuniz-

ation sites have signs indicating that they provide childhood

and maternal immunizations, and promotion posters were

seen in only few immunization sites and other MCH-FP

clinics such as ‘outreach’ sites, which are not located in

permanent health facilities and usually provide

immunizations once a week or once a month. Although in

Bangladesh as a whole 88% of vaccinations are given at

outreach sites, only 45% of those given in the urban areas are

provided there (EPI 1995a). Proximity to the nearest EPI site

is a predictor of utilization of immunization services (Bhuiya

et al. 1995; Perry 1997). Increasing the number of outreach

sites in the slums would likely increase access rates and, more

importantly, coverage rates.

Zone 3 MCH-FP clinic staff who do not provide

immunizations have an incomplete understanding of the

recommended immunization dosage schedule. Such

knowledge is essential for these staff to be able to promote

immunizations among their clients. Mothers have a limited

knowledge of the diseases against which their child had been

immunized: approximately half of the mothers thought their

child had been immunized against a disease which is not, in

fact, preventable through immunization. In addition, there is

a widespread misperception among these mothers (and

perhaps among the providers too) that children aged over 1

years are not eligible and should not be vaccinated.

Other studies in Bangladesh have shown that, although

parents are aware of the need for their children to obtain

immunizations (Khan et al. 1990; FHEP 1995), knowledge of

parents regarding the reasons for immunization and the

immunization schedule remains limited (EPI 1994; Laston et

al. 1993). Furthermore, there is a general perception in the

population that vaccines protect from all illnesses instead of a

specific few and that there is no real difference between one

immunization injection and another. Therefore, it is common

for clients to think that 1 or 2 doses are sufficient (Blanchet

1989; EPI 1991). Another important misconception is the

belief that measles is a good and healthy event for a child and

that measles-associated complications (such as diarrhoea,

pneumonia, and malnutrition) are not related to measles

since they do not necessarily immediately follow the episode

of measles itself (Blanchet 1989).

Immunization coverage levels are greater among those with

a better knowledge of the immunization schedule (Khan et al.

1990; FHEP 1995), and lack of information is one of the

reasons why mothers fail to complete the immunization

schedule for themselves or their child (Laston et al. 1993).

However, this does not necessarily imply that increasing

knowledge is the major or only reason that mothers do not

utilize immunization services. Lack of information was also

the main reason for nonparticipation in the 1995 National

Immunization Day campaigns for polio immunization and

Vitamin A administration (Battacharya & Khanam 1995; EPI

1995b; Quaiyum et al. 1996). Another deterrent is fear of

side-effects, particularly in pregnant women. Even in urban

areas, the belief persists that measles is caused by Sitala, the

goddess of epidemics, and that neonatal tetanus is caused by

bhut, an evil spirit (Blanchet 1989). Those who adhere to this

belief are unlikely to accept the importance of immunizations

for the prevention of these diseases.

More than one-quarter of the under-twos do not have an

immunization card, and most of the married women of

reproductive age who had ever been pregnant do not have a

TT card. Nationally, one-half of young children do not have

an immunization card (Mitra et al. 1994; EPI 1995a), and the

great majority of women do not have a TT card (EPI 1995a).

There is also evidence that immunization providers do not

remind their clients to guard their cards carefully when they

give them to their clients (EPI 1991).

All women who received a TT immunization were

pregnant at the time. Most were given a TT immunization at

a clinic where prenatal care is not provided, but only 1 client

was referred to another clinic for prenatal care. Even in the

clinics where prenatal services beyond TT immunization are

provided, they are not rendered on the same day.

Certain limitations of the study should be borne in mind.

First of all, the findings may not be entirely applicable to

other urban areas of Bangladesh or beyond, although they

are very likely to be appropriate, at least as a starting point,

for other parts of Dhaka and urban areas of Bangladesh or

other developing countries with moderately well-developed

immunization programmes. Secondly we observed only 46

women who were vaccinated and may not be entirely

representative of the overall process of immunization

provision, even in Zone 3. Thirdly, most of the data on which


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981-992 TMIH333 15/12/98 12:24 pm 89



this report is based were obtained as part of the Needs

Assessment Study of the MCH-FP services in Zone 3, and it

was not possible to explore in greater detail the various

quality dimensions related specifically to EPI services. Lastly,

structural conditions which may affect the overall quality of

immunization services were not systematically addressed.

Such conditions include the health information system and

procedures for tracking defaulters in need of immunizations,

integrating prenatal care with TT immunization (and more

generally all MCH-FP services), minimizing missed

opportunities for immunization promotion or administration,

and setting the geographical location of EPI sites and opening

hours. Improving the quality of immunization services in

Zone 3 will require that these issues be more thoroughly

addressed. This task is not as easy as it might seem on the

surface, however, since multiple types of health workers are

involved: from national and municipal EPI programmes, other

government health providers, and various NGOs. The

principal value of our assessment lies in using it to improve

the quality of services.

Implications for the urban and national EPI Programme in

Bangladesh

Urban EPI activities should continue as a special focus of the

national EPI programme, with special attention paid to the

slum population. First of all, a continued rapid growth of the

urban population is expected over the next decade,

particularly in the slum areas. Secondly, the rate of

transmission of communicable vaccine-preventable diseases

(measles in particular) is facilitated by the close proximity of

people in the crowded and densely populated urban areas.

Thirdly, illiterate slum women must overcome major obstacles

to obtain the full complement of immunizations for

themselves and their children. They are under severe time

constraints, particularly if employed, and often unable to

obtain immunizations for their child because of inappropriate

opening hours or the long wait involved (Blanchet 1989;

Jinnah 1993). Fees are another deterrent among urban slum

women (Blanchet 1989). Urban EPI activities will need to

concentrate on improving coverage in slum areas since it is

much worse than in more privileged areas (Perry et al. 1997;

1998a, b).

Now that overall coverage is beginning to reach high levels,

the next logical step in the maturation of the EPI programme

is to improve quality and begin to develop surveillance

systems. Surveillance systems are necessary for identifying

vaccine-preventable deaths and morbidity and for using this

information to focus on areas of low coverage and where

polio, measles and neonatal tetanus cases are concentrated

due to poverty, malnutrition, lack of access to curative

services, crowding and poor hygiene (BASICS 1996a, b).

Conclusions

Urban areas in developing countries are changing dramatically.

Mechanisms will need to be developed to ensure that women

and children living there have ready access to immunization

services and that existing immunization services are optimally

utilized. The resources available, both in terms of manpower

and facilities, will need to expand to accommodate the rapidly

growing population. Planning for the promotion of EPI

services in urban areas, particularly slums, will need to

incorporate one central principle demonstrated by numerous

studies in Bangladesh: person-to-person contact, particularly

from a health worker visiting the home, is a key strategy for

motivating clients to complete the series of immunizations

which they and their children need (Battacharya & Khanam

1995; EPI 1995b; FHEP 1995; Quaiyum et al. 1996; Perry et al.

1997; 1998a, b). One untapped potential source for person-to-

person communication are the ubiquitous pharmaceutical

shops which so far have not participated in the promotion of

immunizations (Mookherji et al. 1996).

Bangladesh is a global leader in its support for and

participation in EPI activities. The unprecedented success of

the National Immunization Days in Bangladesh for polio

eradication and vitamin A distribution, reaching 97% of the

target children in 1996 (D.H. Sniadack, personal

communication), indicates the high level of trust and

confidence which the Bangladesh people have in the quality of

the national EPI programme and the capacity of the

governmental and private sectors to work together toward the

achievement of common goals (EPI 1995a). The potential

exists to build on this trust and confidence to further improve

the quality of EPI activities. Improvements such as those

recommended here will further enhance the effectiveness of the

EPI programme during the coming decade and assist

Bangladesh in meeting its national goals for elimination of

neonatal tetanus, for polio eradication, and for measles

reduction. The methodology used here is applicable to

immunization programmes in general. Our findings are likely

to be relevant to urban areas in other developing countries

which have attained reasonably well-developed immunization

programmes and moderately high levels of coverage.

Acknowledgements

The authors would like to thank the fieldworkers and the

clients of Zone 3, the participating organizations, and the

ICDDR,B interviewers, field researchers, and data specialists

who participated in this study. Valuable comments on earlier

drafts of this paper were provided by Abdullah H. Baqui, T. O.

Kyaw-Myint, David Sniadack, Youseff Tawfik, and Cris

Tuñon. The comments of an anonymous reviewer also led to

considerable strengthening of the paper.


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