IMPROVING COVERAGE OF TETANUS TOXOID VACCINATION

AMONG PREGNANT MOTHERS ATTENDING ANC SERVICES IN

OBONGI HEALTH CENTER IV

By

DR. ARIKE J K AMOOTI (MBCHB-MaK)

SR. OPERU MILKA (CERT REG MIDWIFERY-JINJA)

MEDIUM-TERM FELLOWS (HEALTH SERVICE IMPROVEMENT)

MENTORS

DR. OPIGO JIMMY – MOYO DISTRICT LOCAL GOVERNMENT

MR. MATOVU JOSEPH – MAKERERE UNIVERSITY SCHOOL OF PUBLIC

HEALTH

FEBRUARY 2015

M A K E R E R E U N I V E R S I T Y

SCHOOL OF PUBLIC HEALTH (MakSPH-CDC FELLOWSHIP PROGRAM)

ii

TABLE OF CONTENTS

TABLE OF CONTENTS _________________________________________________________ii

LIST OF TABLES _____________________________________________________________ iv

LIST OF FIGURES_____________________________________________________________v

DECLARATION ______________________________________________________________ vi

ROLE FELLOWS IN PROJECT IMPLEMENTATION ________________________________vii

ACKNOWLEDGEMENTS _____________________________________________________ viii

ACRONYMS _________________________________________________________________ ix

EXECUTIVE SUMMARY ________________________________________________________x

INTRODUCTION/BACKGROUND _______________________________________________ 1

Background to Obongi Health Centre IV ________________________________________________ 2

LITERATURE REVIEW ________________________________________________________ 3

STATEMENT OF THE PROBLEM _______________________________________________ 6

Problem identification and prioritization ________________________________________________ 6

Root cause analysis_________________________________________________________________ 8

Problem statement__________________________________________________________________ 9

Conceptual framework _____________________________________________________________ 10

PROJECT OBJECTIVES ______________________________________________________ 11

General Objective _________________________________________________________________ 11

Specific Objectives ________________________________________________________________ 11

METHODOLOGY____________________________________________________________ 12

PROJECT OUTCOMES _______________________________________________________ 14

LESSONS LEARNED AND CHALLENGES________________________________________ 16

Lessons learned___________________________________________________________________ 16

Challenges and how they were overcome_______________________________________________ 16

CONCLUSIONS AND RECOMMENDATIONS_____________________________________ 17

REFERENCES ______________________________________________________________ 18

APPENDICES_______________________________________________________________ 20

Appendix 1: Standard Operating Procedure for Administering TT vaccine_____________________ 20

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Appendix 2: Assessment questions for VHT training on TT vaccination ______________________ 22

Appendix 3: Assessment questions for staff training on TT vaccination _______________________ 23

Appendix 4: Training of VHTs on importance of TT vaccination ____________________________ 24

Appendix 5: Marks scored by the VHTs in pre- and post- test_______________________________ 25

Appendix 6: Community sensitization on importance of TT vaccination ______________________ 26

Appendix 7: Follow up meeting mentorship by academic mentors ___________________________ 26

Appendix 8: Locally improvised TT register ____________________________________________ 27

Appendix 9: TT referral form ________________________________________________________ 27

Appendix 10: Follow up form________________________________________________________ 28

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LIST OF TABLES

Table 1: Showing Fellows role in project implementation…………………………………..…..vii

Table 2: Showing identified health service delivery problems……………………….……..…….5

Table 3: Showing the composition of the CQI project team……………………………….……..5

v

LIST OF FIGURES

Figure 1: Showing baseline situation with monthly targets..................................................…....6

Figure 2: Showing Fish bone analysis of the root causes of low TT coverage……….….…….…7

Figure 3: Showing Conceptual framework for the project……………………………..…….…...9

Figure 4: Graph showing results of women vaccinated for TT2-TT5 during project

implementation against baseline………………………………………………………….……...12

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DECLARATION

I, Dr. Arike Joseph Koluni Amooti and Sr. Operu Milka do hereby declare that this end of

project report entitled Improving coverage of tetanus toxoid vaccination among pregnant

mothers attending ANC services in Obongi health center IV has been prepared and submitted in

fulfillment of the requirements of the Medium-term Fellowship Program at Makerere School of

Public Health and has not been submitted for any academic or non-academic qualifications.

Signed …………………………………………………… Date …………………………………

Dr. Arike Joseph Koluni Amooti, Medium-term Fellow

Signed ……………………………….………………… Date …………………...……………

Sr. Operu Milka, Medium-term Fellow

Signed ………………………………………………… Date ………………………………..

Dr. Opigo Jimmy, Institutional Mentor

Signed ………………………………………………… Date ……………………………….

Dr. Violet Gwokyalya, Academic Mentor

Signed ………………………………………………… Date ……………………………….

Mr. Matovu Joseph, Academic Mentor

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ROLE FELLOWS IN PROJECT IMPLEMENTATION

Table 1: Showing Fellows role in project implementation

Name of Fellow Role of Fellow

Dr. Arike J K Amooti He is the in charge of Obongi HC IV. He was the project team leader, he

chaired meetings that led to the identification of the project area, led the

project proposal development process and writing w, made sure project

funds were transferred from the district account to the facility account,

with other team members ensured availability of resources for running

the project activities, participated in training of staff, chaired monthly

review meetings, provided monitoring to ensure project results are

achieved as expected, ensured accountability for the project funds,

participated in project report writing and making presentation on behalf

of the team.

Sr. Operu Milka She is the in charge of the maternal and child health ward, and a

member of the CQI committee. Milka participated in the identification

of the project, writing the project proposal, designing Standard

Operating Procedures (SOPs) for the project, training of staff and VHTs,

sensitization of the community, screening of mothers at ANC,

monitoring project activities and follow up of mothers who missed

appointments. She conducted CMEs, gave health education to mothers

at ANC, participated in project report writing and preparing the final

project presentation which was delivered during the dissemination

workshop.

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ACKNOWLEDGEMENTS

We the Fellows from Obongi health center IV acknowledge the supported received from CDC

through the Uganda Ministry of Health which helped us implement this project.

We thank the leadership of Moyo District Local Government especially the CAO (Mr.

Grandfield Oryono Omonda) and the DHO (Dr. Jimmy Opigo) for allowing us under take this

course and creating the enabling environment for the project both at the facility and at the

district. Our regards also go to the entire District Health team for their input into this project.

We wish to thank our academic mentors (Dr. Violet Gwokyalya and Mr. Matovu Joseph) for

having tirelessly guided us through this Medium-term fellowship program and other academic

mentors and facilitators especially Dr. Ibrahim Kirunda, Dr. Eric Ikoona and Miss Evelyn Akello

who gave us their tireless guidance from project conceptualization, to report writing.

We cannot forget the staff of Obongi HC IV especially Mr. Caeser Acini, Mr. Andaku Linus,

Mr. Dramatiga Justine, Mr. Obulejo Denis and others whom we couldn’t mention. Their team

spirit helped us to achieve. In a special way, we thank the chairperson of the Health Unit

Management Committee (Zaida Sadick) for her active participation right from the beginning of

the project till the end and for having actively mobilized the community.

To our dear VHTs who actively followed up the mothers who missed their appointments for TT

vaccination, we are so grateful for all your contribution.

Lastly and in a special way, we thank the pregnant mothers and the communities at large for

having listened, cooperated, and mobilized others all through the project time. Thank you very

much.

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ACRONYMS

MOH Ministry of Health

TT Tetanus Toxoid

CDC Center for Disease Control and Prevention

MakSPH Makerere University School of Public Health

SIA Supplementary Immunization Activities

WHO World Health Organization

ANC Antenatal Care

VHT Village Health Team

SOP Standard Operating Procedure

DHO District Health Officer

CAO Chief Administrative Officer

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EXECUTIVE SUMMARY

Tetanus Toxoid (TT) coverage among pregnant mothers attending ANC in Obongi health center

IV was identified by the health staff in Obongi as the most pressing service delivery gap. TT

coverage was found to be 32%. This performance was mainly attributed to poor screening of

pregnant women within the antenatal clinic for vaccination status, lack of follow up of pregnant

women due for TT vaccination, health staff having inadequate knowledge on TT vaccination,

and poor documentation of TT vaccination records. The other contributing factors identified

included; poor staff attitudes about TT vaccination, limited knowledge of pregnant mothers

about the importance of TT vaccination, lack of continuous health education to pregnant mothers

about the importance of TT, limited VHTs trained on the importance of following up pregnant

mothers due for TT vaccination and lack of performance review meetings about TT coverage at

the facility. This was further complicated by the low turn up of the mothers for subsequent

antenatal visits.

Various activities were undertaken by the project team to improve this situation. These activities

include; training of staff and VHTs on TT vaccination, developing Standard Operating

Procedures (SOPs) on TT vaccination, community sensitization on TT vaccination; follow up of

all pregnant mothers who missed their TT vaccination, screening of all pregnant mothers at ANC

point and vaccinating all mothers those who are due for vaccination. These activities resulted in

the achievement of 84% of women being vaccinated for TT at ANC point from the baseline of

32% in a period of 6 months.

1

INTRODUCTION/BACKGROUND

Worldwide, tetanus kills an estimated 180 000 neonates (about 5% of all neonatal deaths (WHO,

2002 data) and up to 30 000 women (about 5% of all maternal deaths) each year. In sub-Saharan

Africa, up to an estimated 70,000 newborns die each year in the first four weeks of life due to

neonatal tetanus. This predicament exists, even though neonatal tetanus is eminently preventable

through two injections of tetanus toxoid (TT) during pregnancy and hygienic practices at birth. If

the mother is not immunized with the correct number of doses of tetanus toxoid vaccine, neither

she nor her newborn infant is protected against tetanus.

WHO recommends that all women giving birth and their newborn babies should be protected

against tetanus by immunizing the mother prior to childbirth with TT (WHO 2006). A pregnant

woman should receive at least two doses while pregnant, unless she already has immunity from

previous TT vaccinations. However five doses of TT are recommended and these can ensure

protection throughout the reproductive years and even longer. Antenatal care is the main

programmatic entry point for routine TT immunization but in areas where the health system is

weak, supplemental immunization activities (SIA) are used to deliver TT to all women of

childbearing age in a campaign approach.

All pregnant women should attend antenatal clinic or be reached by health staff in the

community and Antenatal care (ANC) providers should be trained in tetanus immunization. The

vaccine, equipment and supplies (refrigerator, syringes, needles, etc.) needed to conduct tetanus

immunization should be readily available in the health facilities, particularly at ANC services.

WHO further recommends that an effective tetanus vaccination monitoring system should be in

place; including immunization registers, personal vaccination cards and maternal health records.

All pregnant women should be issued a personal immunization card, which should be available

for reference at each ANC visit and at any other contact with the health system throughout life.

Health education activities to increase community awareness of the importance of tetanus

immunization should be carried out. Maternal and neonatal tetanus should be included in the

national surveillance system.

Protection against Tetanus increases with the number of doses received. For maximum

protection, five doses are recommended i.e. TT1-TT5. The first dose (TT1) should be given at

first contact with a pregnant woman or women of child bearing age (15-45 years); TT2 (4 weeks

2

after TT1); TT3 (Six months after TT2); TT4 (One year after TT3) & TT5 (One year after TT4).

In high risk countries like Uganda, all pregnant women should receive at least two doses of

Tetanus Toxoid (TT). The Uganda National Policy Guidelines, 2007 also recommend that TT

should be provided to all pregnant women and women of child bearing age

Background to Obongi Health Centre IV

Obongi Health Center IV is found in Moyo District in Obongi County and is the only Health

Center IV in Moyo District. It has a catchment population of 15825. The population of women of

child bearing age is estimated to be 3640 while that for pregnant women is estimated at 791.

Children under five are estimated at 3165 while those under one year are at 728.

The health facility has 1 medical officer, 2 clinical officers, 3 midwives, 11 nurses, 2 laboratory

assistant, 1 cold chain assistant, 1 health assistant, 1 health educator, 1 record assistant, 3 support

staff and 6 unskilled staff.

The health facility offers Antenatal, HIV/AIDS, TB diagnosis and treatment, EPI, Maternal

health, Child health, Outpatient, In patient, Out reaches, Health promotion and education,

Environmental health, Theatre, Eye care and Mental health services.

In Obongi H/C IV, TT immunization is given as and when the mother comes for antenatal

services at the health facility and during outreaches. However before the project most mothers

din’t have or did not come with TT vaccination cards to show whether or not they received a

vaccine, when they received it and which dose they received. Quite often such mothers missed

immunization. The few who have their TT vaccination cards were given the injection as per the

schedule on the card. During their ANC visits, they were identified and sent to the vaccination

point where they received the vaccine.

3

LITERATURE REVIEW

A total of 35 of the 59 countries that had not eliminated maternal and neonatal tetanus (MNT) as

a public health problem in 1999 have since achieved the MNT-elimination goal (Khan et al,

2015). Neonatal tetanus deaths have decreased globally from 200,000 in 2000 to 49,000 in 2013.

This is the result of increased immunization coverage with tetanus toxoid-containing vaccines

among pregnant women, improved access to skilled birth attendance during delivery, and

targeted campaigns with these vaccines for women of reproductive age in high-risk areas. In the

process, inequities have been reduced, private-public partnerships fostered, and innovations

triggered. However, lack of funding, poor accessibility to some areas, suboptimal surveillance,

and a perceived low priority for the disease are among the main obstacles (Khan et al, 2015).

Some countries especially those in resource limited setting still have a big burden of neonatal

tetanus. In Bangladesh, an estimated 41,000 cases of neonatal tetanus occur annually (Perry H,

Weierbach R, Hossain I, and Islam R.). The scholars argued that although 85% of women with

children under 1 year of age had received two TT immunizations, only 11% of women of

reproductive age had obtained the complete series of five TT immunizations and only 52% of

women of reproductive age had received one or more TT immunizations. They noted that

characteristics associated with TT immunization status included the following: educational level

of the woman, distance from the nearest immunization centre, and level of contact with family

planning field workers (Perry et al). They also noted additional characteristics that influenced

women's TT immunization status which included age, marital and working status, recent

migration from rural to urban areas, and number of children. They recommended that, reducing

missed opportunities for promotion of immunization as well as targeting home visitation of

women in need of immunizations constitute approaches to improving TT coverage.

Maral I, Baykan Z, Aksakal FN, Kayikcioglu F, Bumin MA also found various factors affect

tetanus toxoid (TT) vaccination coverage during pregnancy in reproductive-age women. For

example, in a hospital in Ankara (Turkey) four-hundred and ninety-three postpartum women

who had live births were interviewed and information was collected on the mothers' socio-

demographic characteristics, TT vaccination history, and prenatal care during the pregnancy

studied. They found out that the rates for no vaccination, one-dose vaccination, and two-dose

vaccination were 53.3%, 18.9%, and 27.8%, respectively. The vaccinated women (with at least

one dose) were significantly younger, of lower parity, and had attended more prenatal care visits

4

than the unvaccinated women. And also of the women who attended at least one prenatal care

check-up, only about half were vaccinated. They noted that significantly more rural women were

vaccinated against tetanus than urban women. Current vaccination rates with TT during

pregnancy were found to be well below universal levels. Hence they suggested that Turkey needs

to launch effective mass media campaigns that target urban and suburban populations, and

inform and motivate women to request vaccination against tetanus.

In 1999, the the World Health Organization (WHO), the United Nations Children Fund

(UNICEF), and the United Nations Population Fund (UNFPA) relaunched the “Maternal and

Neonatal Tetanus Elimination” initiative and called for total elimination of maternal tetanus .

This collaboration also highlighted 5 major strategies to achieving this target;

delivery by skilled birth attendants (SBAs) to ensure clean delivery practices

immunization of women during pregnancy (at fixed sites or through outreach) with

TTCVs

immunization of women of reproductive age (WRA) with TTCVs, through

supplementary immunization activities (SIAs) in high-risk areas and

surveillance for NT.

Since the 1980s, TT has been part of routine immunization programs, especially in developing

countries, to protect pregnant women and their future newborns from tetanus (WHO, 2014).

Administration of properly-spaced doses of TTs during the antenatal period can reduce the

incidence of NT by up to 88%–100%, and can help to achieve maternal and neonatal tetanus

(MNT) elimination in countries with a relatively strong and equitable health system (Darmstadt

et 2005). The number of doses of TT administered during antenatal checkups will depend on the

previous vaccination status of the women. Previously unvaccinated women will require five

properly-spaced doses of TT. Reported TT2+ coverage (Deming et al 2002) has progressively

increased from 62% in 2000 to 75% in 2012 at the global level, but dropped to 65% in 2013

(WHO 2014). The interpretation of these numbers has to be approached with caution, as

precision issues are well recognized.

5

Challenges in achieving MNT elimination

In spite of the immense success of the MNT Elimination initiative that has contributed to both

the MDGs related to childhood and maternal mortality (MDGs 4 and 5), the program is also

facing some challenges as it approaches its ultimate goal. These challenges include inadequate

access especially in areas that are hard to reach and those that have been affected by the

insurgency, cultural barriers and beliefs against vaccination, and poor monitoring system among

others (Pallikadavath, 2004, Nisar, 3003).

Opportunities

Despite the above mentioned challenges, there are opportunities to achieve MNT elimination in

all countries. Scholars have shown that there is need for innovative approach to reach

inaccessible areas, integrating service delivery, strengthening social mobilization and health

education (Boggs, 2014).

6

STATEMENT OF THE PROBLEM

Problem identification and prioritization

The staff in Obongi HC IV in a meeting identified a number of priority areas and voted for the

most pressing one to take it as a project of their interest as shown in the table below;

Table 2: Showing identified health service delivery problems

According to the table above, low coverage of tetanus toxoid vaccination among pregnant

women emerged the most pressing problem at the facility and the team agreed to prioritize it and

take it on as the improvement project for Obongi health IV. The team further selected a project

team to analyze the problem further and spearhead improvements.

Table3: Showing the composition of the CQI project team

Names Cadre Title

Dr. Arike Joseph Medical Officer I/C Obongi H/C IV

Sr. Milka Operu Nursing Officer/Midwife I/C Maternity

Acini Ceaser Cold chain Assistant EPI focal person

Andaku Linus Health Information Assistant HMIS focal person

Possible project areas Scores

Low ANC 4th Visit 4

Low TT coverage for non pregnant women of child bearing age 3

Low TT coverage in pregnant women attending ANC services 9

Poor documentation, data management and usage 2

Poorly maintained facility compound 1

Lack of knowledge about equipment maintenance 2

Poor medical waste management and disposal 4

7

The team reviewed the antenatal records of the past five months to establish the proportion of

mothers seen in ANC who received TT vaccination. The team first screened records of mothers

who had been received in Obongi HC IV in the previous months and established those who were

eligible for the various doses of TT in the subsequent months. The team then followed the

records of those mothers in the subsequent ANC visits to establish whether they actually

received the vaccination. It was discovered that overall only 31.8% of women received in ANC

were given the vaccine. This proportion reduces with the dose of TT vaccine. The table below

shows TT vaccination of pregnant mothers attending ANC services from Nov, 2013 to March,

2014 at Obongi health center IV.

Figure 1: showing baseline situation with monthly targets

Health Unit Catchment Population 15825

Annual target for pregnant women 791

Monthly total TT target (TT2-TT5) for pregnant women 66

8

Root cause analysis

Figure 2: Fish bone diagram showing the analysis of the root causes of low TT coverage

The biggest contributors to low TT coverage were; poor linkage of mothers from the ANC point

to the vaccination point, poor documentation of TT vaccination status of women and actions

taken by the midwives, poor screening of pregnant women for TT vaccination status, and lack of

follow up for women who miss vaccination.

Low TT coverage amongpregnant mothers attendingANC services in Obongi H/C IV

Lack of health education topregnant mothers about theimportance of TT Vaccination

Processes

Poor screening of pregnantwomen for TT vaccination

Staff

Lack of performancereview meetings for TTvaccination

Poor staff attitudeabout TT vaccination

Inadequate knowledge ofstaff about TT vaccination

Lack of follow up ofpregnant mothers duefor TT vaccination

Poor documentation ofTT vaccination records

Community

Poor linkage of mothers fromANC to vaccination point

Ignorance ofpregnant mothersabout TT vaccination

VHTs lack knowledgeon importance offollow up of mothersfor TT vaccination

9

Problem statement

There was low TT coverage among pregnant women attending ANC services at Obongi health

center IV. Data of November 2013 to April 2014 showed that on average the facility received

131 pregnant women a month for ANC services but only 32 % received TT2-TT5 vaccination

(ANC register).

This performance was mainly attributed to poor screening of pregnant women within the

antenatal clinic for vaccination status, lack of follow up of pregnant women due for TT

vaccination, health staff having inadequate knowledge on TT vaccination, and poor

documentation of TT vaccination records. The other contributing factors identified included;

poor staff attitudes about TT vaccination, ignorance of pregnant mothers about the importance of

TT vaccination, lack of continuous health education to pregnant mothers about the importance of

TT, limited VHTs trained on the importance of following up pregnant mothers due for TT

vaccination and lack of performance review meetings about TT coverage at the facility. This was

further complicated by the low turn up of the mothers for subsequent antenatal visits.

Though we had not registered any neonatal tetanus in so many years, if this low TT coverage

among pregnant mothers attending ANC services in Obongi health center IV remained

unattended to, the facility would register cases of neonatal tetanus.

Therefore, the team set out to improve the coverage of TT (TT2-TT5) vaccination among

pregnant women attending antenatal care at Obongi H/C IV by addressing the above root causes

so as to increase the protection of mothers and their unborn babies. Specifically we aimed to

improve this coverage of TT from 32% to 90 % in 6 months.

10

Conceptual framework

Figure 3: Conceptual framework for the project

Lack of follow up ofpregnant mothers duefor TT vaccination

Poor documentation ofTT vaccination records

Poor screening ofpregnant women for TTvaccination

VHTs lack knowledge onimportance of follow upof mothers for TTvaccination

Inadequate knowledgeof staff about TTvaccination

Ignorance of pregnantmothers about TTvaccination

Poor TTvaccinationprocesses

Poor staffattitude andskills in TTvaccination

Poorcommunityattitude andknowledge

Low TT coverageamong pregnantmothersattending ANCservices inObongi H/C IV

11

PROJECT OBJECTIVES

General Objective

To improve TT2-TT5 coverage from 32% to 90% in pregnant women attending ANC services in

Obongi health center IV by December 2014.

Specific Objectives

1 To establish a screening and follow up system at the facility to track pregnant women for

TT vaccination.

2 To strengthen linkage of mothers from ANC to vaccination point in the facility by

November, 2014.

3 To improve TT documentation, management and usage in Obongi Health Centre IV.

12

METHODOLOGY

We strengthened the screening of pregnant mothers and subsequent TT vaccination for

those who were due by;

Building the capacity of staff in TT vaccination. We trained 30 facility staff to equip them

with skills of vaccination. The training addressed general knowledge on vaccination, and specific

knowledge about TT vaccination including recommended doses and schedule, health education

recommended for the pregnant women and the accompanying documentation. Staff who attended

the training included, nurses, midwives, vaccinators, clinical officers and nursing assistants. Staff

were also sensitized on implications of not giving TT vaccination to pregnant women.

Following the training, a focal person was chosen to oversee the progress in TT vaccination

for pregnant women.

Standard Operating Procedures (SOPs) were developed (refer to appendix) to guide staff on

the process for screening and ensuring all mothers receive the required vaccination.

The senior midwife also continuously supported the other midwives through on-job mentorship

to make sure the new changes take effect and that all staff knew what to do with the mothers.

We also reinforced the trainings with regular continuous professional development sessions.

TT register books were improvised to register mothers.

We established a screening point within ANC at which the vaccination status of all the

mothers who came for ANC was established. We then escorted the mothers to the vaccination

point (which was not within ANC) to receive their due doses.

Sensitization of pregnant mothers and the rest of the community. Mothers were given health

education at ANC about importance of vaccination and general community members in the ten

villages served by the health facility were sensitized about TT vaccination to enable them

support the pregnant women and remind them to receive the vaccination. So on a daily basis

during antenatal services; mothers went through health education, their TT cards screened for

their TT status, then after their full antenatal service, they were escorted to the vaccination point

for vaccination. Their details were entered into the improvised TT register book and then the TT

card was marked accordingly and tallying done.

13

We established a follow up system for pregnant mothers for TT vaccination by;

Involvement of the village health team members (VHTs). In order to get the VHTs on board,

we trained 20 VHTs to follow up mothers who miss appointments. Midwives would records

every mother given vaccination then issue them appointments for their next dose in the TT

register book. For those mothers who missed their appointments, the midwife compiled the list

and issued it to the VHT who then followed the mothers in their homes. TT referral forms were

designed to help VHT refer these mothers to the vaccination point at the facility.

Follow up of mothers who missed their appointments. Monthly audits were also done, lists of

mothers who miss their appointments generated and then they were followed by the VHTs.

Referral forms were used by the VHTs to refer these mothers to the Health Facility to be

vaccinated or they could be followed by the health staff who move with vaccines, tally sheets

and the improvised TT register book, and the mothers could be vaccinated from their homes.

We improved documentation, management and usage by;

Conducting monthly reviews in which the number of women vaccinated for the various TTs

were counted and tabulated. We improved a TT register to help track the women vaccinated and

improved the filling system

14

PROJECT OUTCOMES

Outcome 1:

Overall, 84.5% (446) of the 528 mothers due for vaccination received their TT vaccination. Of

those vaccinated, 90% (402) received vaccination at the vaccination point and 10% (44) were

vaccinated upon being followed up by the health workers or being referred by the VHTs for TT

vaccination after missing an appointment. Another 12% (6) out of 50 mothers who missed

appointment were not found at home upon follow up as some had travelled and others were busy

in gardens far from their known homes. There was improvement in the knowledge gap of the

staff as screening and vaccination was done more intensively in line with SOP designed.

Figure 4: Graph showing results of women vaccinated for TT2-TT5 during project

implementation against baseline

Outcome 2:

There was active linkage of mothers from ANC to vaccination point. Mothers had better

understanding of the importance of TT vaccination as most mothers moved with their TT cards

for ANC services, which was not the practice before. This eased the screening process. Mothers

Baseline region

Result region

15

would move willing from ANC to vaccination point (without complaining) after being

sensitized.

Outcome 3:

Documentation, data management and usage improved as tetanus toxoid register was improvised

which helped in providing detailed information about the mothers TT status. This was evidence

in the weekly review meeting by the project team when it was noted that documentation had

improved and staff were able to discuss the data captured. Also additional information was

captured in the ANC register which improved the completion of the ANC register.

Outcome 4.

The project led to increased involvement of the VHTs in project activities and more team work

between the VHTs and the staff at the facility.

Other outcomes included; improved staff skill sin vaccination, allocation of the EPI focal person

at the facility who now oversee all activities related to immunization, enhanced team spirit,

improved community awareness on TT vaccination and improved appreciation of quality

improvement by the staff which has led to some improvements in others service areas.

16

LESSONS LEARNED AND CHALLENGES

Lessons learned

There is need to ensure availability of the right tools in any improvement project. It helps

in monitoring the project.

SOP help to ensure that the right things are done at the right time.

Involvement of VHTs and community leaders is key in achieving results.

Improvement of service for pregnant women calls for active linkage in order to reduce or

avoid loss of mothers in between service point

Challenges and how they were overcome

Some mothers do not keep appointment date.

o Therefore active follow up of these women was initiated

Obongi Health centre IV being at the landing site, some mothers were very mobile.

o VHTs help a lot in tracking these mothers, informing the facility staff when

mothers are out of the village and following them up as soon as they return.

Some mothers lost their TT cards.

o Therefore we had to issue them other TT cards and also we made use of the TT

register book to extract available information about them.

Most mothers do not have phones hence communication for follow up was difficult.

o This was solved by ensuring staff capture the right directions to client homes and

use of VHTs to help in tracing clients

Most mothers spent quite a lot of time in the field (garden) hence getting them was

difficulty

o VHTs were used to check on them and they could be referred to the facility for

vaccination

17

CONCLUSIONS AND RECOMMENDATIONS

Overall there was an improvement from 32% to 84.5% in TT2-TT5 vaccination of pregnant

women attending ANC in Obongi health center IV in Moyo district. This success was due to

improving staff knowledge on TT vaccination, strengthening the sensitization of women on the

importance of TT vaccination and engagement of VHTs in improving TT vaccination among

other changes tested. We did not achieve the 90% target because of the change in population

numbers as provided by UBOS 2002 (15825) which differed from the figure provided by UBOS

2014 (7152). However 84% was a very good improvement considering the short time of project

implementation. The team intends to maintain the quality improvement measures until it the

facility registers 100% success rate in immunizing all pregnant women attending ANC in Obongi

Health Centre IV. The quality improvement team with the leadership of the fellows will continue

with regular CMEs for staff to keep them updated about the importance of TT vaccination. The

team will also regularly review the processes mothers go through to receive the vaccination as

well as analyze facility performance data in order to identify bottle necks to this intervention.

The involvement of the community has been very vital in this project. We intend to maintain the

close collaboration with our community structures especially the VHTs and the Health Unit

Management committee who help us to reach the community but also represent the community

in identifying bottle necks in service delivery at the facility. The improvements registered will be

scaled up to lower health facilities through supporting health workers understand the importance

of TT vaccination, improve their records and collaboration with community structures.

We recommend that;

1. The District Health Team ensures continued provision of TT vaccines to the facility and

strengthens the supervision of provision of EPI services to the facility.

2. The fellows together with other skilled health workers continue with on-job mentorship and

support supervision of the lower level health workers to keep up the good practices and to

improve staff skills

3. The fellows work with the staff of Obongi HC IV to scale up improvement strategies to other

service delivery units within the health facility

4. The facility team should strengthen the use of data by regularly collecting and analyzing data

and displaying, discussing and sharing performance with the districts

5. Ministry of Health should design TT register books to easy record keeping

18

REFERENCES

1. Boggs MK, Bradley PM, Storti CZ (2006). Saving Newborn Lives: Tools for Newborn Health.

Washington: Save the Children Federation; 2006. [Accessed September 30, 2014]. Available from:

http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-

df91d2eba74a%7d/communication-for-immunization-campaigns-for-maternal-and-neonatal-tetanus-

elimination.pdf

2. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L (2005). Evidence-

based, cost-effective interventions: how many newborn babies can we save?

3. Deming MS, Roungou J, Kristiansen M, et al (2002). Tetanus toxoid coverage as an indicator

of serological protection against neonatal tetanus.

http://www.who.int/immunization/monitoring_surveillance/data/gs_gloprofile.pdf?ua=1.

4. Khan R, Vandelaer J, Yakubu A, Raza AA, Zulu F (2015). Maternal and neonatal tetanus

elimination: from protecting women and newborns to protecting all.

5. Maral I, Baykan Z, Aksakal FN, Kayikcioglu F, Bumin MA. Tetanus immunization in

pregnant women: evaluation of maternal tetanus vaccination status and factors affecting rate

of vaccination coverage.

6. Mosiur M, and Rahman (2004) Determinants Of The Utilization Of The Tetanus Toxoid

(TT) Vaccination Coverage In Bangladesh: Evidence From A Bangladesh Demographic

Health Survey.

7. Nisar N, White E (2003). Factors affecting utilization of antenatal care among reproductive

age group women (15–49 years) in an urban squatter settlement of Karachi. J Pak Med

Assoc. 2003;53:47–53.

8. Pallikadavath S, Foss M, Stones WR (2004). Antenatal care: provision and inequality in rural

north India. Soc Sci Med. 2004;6:1147–1158.

9. Perry H, Weierbach R, Hossain I, and Islam R (1998). Tetanus toxoid immunization

coverage among women in zone 3 of Dhaka city: the challenge of reaching all women of

reproductive age in urban Bangladesh.

10. Teklay Kidane (2004). Factors influencing TT immunization coverage and protection at birth

coverage at Tselemti District Ethiopia.

11. World Health Organization Global and regional immunization profile (2014). [Accessed

September 14, 2014]. Available from:

19

12. World Health Organization (2014). Second and subsequent doses of tetanus toxoid: reported

estimates of TT2+ coverage. [Accessed September 2, 2014]. Available from:

http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tscoveragett2plus.ht

ml.

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APPENDICES

Appendix 1: Standard Operating Procedure for Administering TT vaccine

1. Wash hand with soap and water, drip dry

2. Hold the TT vial between the thumb and the middle, check the vaccine for condition of

the vial and its expiry date

3. Seek the vial such that the sediments at the bottom mix completely with the liquid. If the

vaccine is not well mixed, the correct does cannot be given. If you suspects that the

vaccine has been frozen and thawed carry out the seek test

4. Remove the center of the metal cap from the vial

5. Draw 0.5ml of the TT vaccine using the ADS. Pull the ADS until you feel a click.

6. Ask the client whether she prefers her immunization to be in her left of right arm.

7. Clean the injection site using a swab and clean water

8. Then give the vaccine intramuscular in the upper arm, place a dry and a swab at the

injection site. Request the client to hold firmly to prevent infection or bleeding. Do not

massage the site

9. Put the used syringe in the safety box, do not recap the used syringe

10. Wash hand before administering to every client whenever necessary

Administration of TT vaccine

Check list for administering of tetanus vaccine

TT in a 20 dose vial

1-2 tables, chairs, benches or mats for sitting

1-2 vaccine carriers containing vaccines wrapped in polythene bags with

reconditioned ice packs, thermometer and sponge

Galley pots and kidney dishes or clean plastic bowels

Auto disabling syringes and needs (ADS 0.5ml)

Safety box for disposing needles and syringes

Cotton wool, tally sheets and pens

Cotton with cool boiled water for cleaning injection site (1ltr)

Hand washing facility with soap

21

2 biohazard, one for empty vials and the other for wet swabs

Plastic sitting, 1m

Calendar to be used for giving return dates for subsequent doses

TT cards

TT register

Paraffin and match box

22

Appendix 2: Assessment questions for VHT training on TT vaccination

Instructions:

Circle the correct answer

1. Write TT in full sentence

a) Treatment

b) Tetanus toxoid

c) Cause

d) Poverty

2. What causes tetanus?

a) Clostridium tetani

b) Fungal

c) Ecoli

d) Bacteria

3. Who is tetanus transmitted?

a) Eating feces

b) Blood transfusion

c) Eating soil

d) Wound contaminated by soil or animal excreta

4. Give five ways of spreading tetanus

i) …………………………………………………………………………………………..

ii) …………………………………………………………………………………………..

iii) …………………………………………………………………………………………..

iv) …………………………………………………………………………………………..

v) …………………………………………………………………………………………..

5. How is tetanus prevented?

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

6. How many times a pregnant mother does get tetanus toxoid vaccine?

...............................................................................................................................................

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Appendix 3: Assessment questions for staff training on TT vaccination

Instructions: Read and circle the correct answer from 1-5

1. What causes tetanus toxoid?

a) Fungal

b) Ecoli

c) Clostridium tetani

d) Bacteria

2. How is tetanus transmitted?

a) Eating feces

b) Blood transfusion

c) Eating soil

d) Wound contaminated by soil or animal excreta

3. Write TT in full

a) Treatment

b) Tetanus toxoid

c) Cause

d) Poverty

4. How is tetanus prevented?

a) Treatment

b) By taking drugs

c) By vaccination

d) Health education

5. What is the incubation period of tetanus?

a) 1-2 days

b) 2-3 days

c) 7 days

d) 3-7 days

6. Write VVM in full

………………………………………………………………………………………………

7. What are the four stages of VVM?

24

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

8. What is the recommended storage temperature of TT vaccine

………………………………………………………………………………………………

9. Give 3 signs and symptoms of neonatal tetanus

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

10. Describe the five intervals of TT vaccine administration to a mother

i) ………………………………………………………………………………………….

ii) ………………………………………………………………………………………….

iii) ………………………………………………………………………………………….

iv) ………………………………………………………………………………………….

v) ………………………………………………………………………………………….

Appendix 4: Training of VHTs on importance of TT vaccination of pregnant mothers

25

Appendix 5: Marks scored by the VHTs in pre- and post- test

26

Appendix 6: Community sensitization on importance of TT vaccination in pregnant

mothers

Appendix 7: Follow up meeting mentorship by academic mentors (Dr. Violet Gwokyalya

and Dr Eric Ikoona), with the head scurf is the chairperson HUMC (Zaida Sadick)

27

Appendix 8: Locally improvised TT register for capturing detailed TT records/information

Appendix 9: TT referral form used for referring clients who missed appointment

28

Appendix 10: Follow up form with list of clients followed