Lattest Document 2003

QUALITY OF IMMUNIZATION SERVICES IN PRIMARY HEALTH
CARE FACILITIES OF WOLAITA ZONE, SOUTH ETHIOPIA
BY: YIBELTAL KASSA (Bsc.)
A thesis submitted to the Department of health planning and health service

management, School of Graduate studies, Jimma University; in Partial
Fulfillment for the Requirement for Masters of Public Health (MPH)
i
QUALITY OF IMMUNIZATION SERVICES IN PRIMARY HEALTH
CARE FACILITIES OF WOLAITA ZONE, SOUTH ETHIOPIA
BY: YIBELTAL KASSA (Bsc.)
ADVISORS: CHALLI JIRA (MPH, CHMPP, DVLDP) Professor
YOHANNES EJIGU (BSc. MSc)
Jimma, Ethiopia
May, 2010
ABSTRACT
ii
Background: Increasing the quality of immunization services is one of the strategies to reach at
objective of EPI in Ethiopia. Infant and childhood mortality in Ethiopia are still among the
highest in the world. Each year more than one-third of a million children die from infectious
disease where the prevention and control measures are available.
Objective: Objective of this study was to assess the quality of EPI service in primary health
care facilities.
Methods: The study used facility based cross sectional study design. Both quantitative and
qualitative data was collected by using different data collection methods. Source population:
mothers who utilize EPI service in the selected health facilities and total primary health care
facilities of Wolaita zone.
Result: Majority of health facilities found to have adequate supplies and equipments but
difference was seen between health centers and health posts. About one third of health posts lack
refrigerators. One third (33.3%) of the observed health centers were found with temperature in
the fridge below or above recommended range. All health centers used AD syringes for injection
but only 3 of 36 (8.34%) observed procedures were sterile. Three hundred forty nine (86.2%) the
responded mothers were satisfied by EPI service and technical competence of the provider,
consultation, confidentiality, waiting time, explanation about immunization and waiting area
structure of EPI service were found to be important predictors of client satisfaction. Two
hundred forty eight (61.2%) of clients were knowledgeable about immunization.
Conclusion: Majority of health facilities rated as adequate in terms of equipment and supply
necessary for EPI services. But majority of health posts lack refrigerators. Below or above
normal temperature in the fridge and inappropriate arrangement of vaccines in the fridge were
found to be the key constraints concerning vaccine handling and cold chain management.
Factors related with service provider were found to be important determinants of client
satisfaction. Although it has been argued that clients do not know what the technically acceptable
level of care is, it is agreed that dissatisfaction is an indication that services delivered are lacking
in some aspects of provider related factors.
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ACKNOWLEDGEMENT
I would like to thank my advisors, Professor Challi Jira and Mr. Yohannes Ejigu for their
professional, invaluable and compassionate comments and advices which helped me to
accomplish this study.
Secondly, I am very glad to acknowledge all staffs and secretaries of department of health
planning and health service management who helped me in constructive ways toward
accomplishment of study.
Thirdly my great gratitude goes to the respondents, Wolaita zone health department and all
district health offices, data collectors and supervisors for their invaluable cooperation and
support. Finally, I couldn’t oversight contribution my classmates, friends and family.
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TABLE OF CONTENTS
TABLE OF CONTENTS ........................................................................................................................ v
LIST OF TABLES ................................................................................................................................ vii
LIST OF FIGURES ............................................................................................................................... vii
ABBREVIATIONS .............................................................................................................................. viii
CHAPTER 1: INTRODUCTION ............................................................................................................ 1
1.1 BACKGROUND ..................................................................................................................... 1
1.2 STATEMENT OF THE PROBLEM .............................................................................................. 3
CHAPTER 3: SIGNIFICANCE OF THE STUDY ................................................................................. 10
CHAPTER 4: OBJECTIVES ................................................................................................................. 11
4.1 GENERAL OBJECTIVE ............................................................................................................. 11
4.2 SPECIFIC OBJECTIVES ............................................................................................................ 11
CHAPTER 5: METHODOLOGY.......................................................................................................... 12
5.1 STUDY AREA AND PERIOD .................................................................................................... 12
5.2 STUDY DESIGN ........................................................................................................................ 12
5.3 POPULATION ............................................................................................................................ 12
5.3.1 SOURCE POPULATION ..................................................................................................... 12

5.3.2 STUDY POPULATION........................................................................................................ 12
5.4 SAMPLE SIZE AND SAMPLING TECHNIQUE ....................................................................... 13
5.5 DATA COLLECTION AND MANAGEMNT ......................................................................... 15

5.5.1 DATA COLLECTION INSTRUMENTS .............................................................................. 15
5.5.2 DATA COLLECTORS ......................................................................................................... 15
5.6 STUDY VARIABLES ................................................................................................................. 16
5.7 ANALYSIS ................................................................................................................................. 17
5.7.1 ANALYSIS OF QUANTITATIVE DATA ............................................................................ 17

5.7.2 ANALYSIS OF QUALITATIVE DATA .............................................................................. 17
5.8 DATA QUALITY CONTROL .................................................................................................... 17
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5.9 OPERATIONAL DEFINITIONS ................................................................................................ 17
5.10 ETHICAL CONSIDERATIONS................................................................................................ 18
5.11 DESSEMINATION PLAN OF THE STUDY FINDINGS ......................................................... 18
CHAPTER 6: RESULT ......................................................................................................................... 19
6.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS ....................................................................... 19
6.2 STRUCTURAL QUALITY ASSESSMENT................................................................................ 20
6.2.1 GENERAL CONDITION OF COLD CHAIN ROOMS......................................................... 20

6.2.1 VACCINE AVAILABILITY ................................................................................................ 20
6.2.2 VACCINE CONTAINERS ................................................................................................... 21
6.2.3 OTHER NECESSARY RESOURCES .................................................................................. 22
6.2.4 QUALITY ASSESSMENT OF EQUIPMENTS AND SUPPLIES......................................... 23
6.3 ASSESSMENT OF PROCESS QUALITY .................................................................................. 24
6.3.1 PROCESS QUALITY PERCEIVED BY CLIENTS .............................................................. 24

6.3.2 VACCINE HANDLING AND STOCK MANAGEMENT .................................................... 25
6.3.3 VACCINE TEMPERATURE MONITORING ...................................................................... 26
6.3.4 INJECTION SAFETY .......................................................................................................... 27
6.4 ASSESSMENT OUTCOME QUALITY ...................................................................................... 28
6.4.1 CLIENT SATISFACTION.................................................................................................... 28

6.4.2 MOTHERS’ KNOWLEDGE ON IMMUNIZATION ............................................................ 29
CHAPTER 7: DISCUSSION ................................................................................................................. 32
CHAPTER 8: STRENGTHS AND LIMITATIONS OF THE STUDY .................................................. 36
8.1 STRENGTHS OF THE STUDY .................................................................................................. 36
8.2LIMITATIONS OF THE STUDY ................................................................................................ 36
CHAPTER 9: CONCLUSION AND RECOMMENDATIONS.............................................................. 37
9.1 CONCLUSION ........................................................................................................................... 37
9.2 RECOMMENDATIONS ............................................................................................................. 38
REFERRENCES ................................................................................................................................... 39
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ANNEX 2. QUESTIONNAIRE AND CHECKLISTS ........................................................................... 42
LIST OF TABLES
Table 1-Summary for all the methods used ............................................................................................ 16
Table 2–Socio-demographic characteristics of mothers/caretakers with babies under 1 year in Wolaita
zone, March, 2010 ................................................................................................................................. 19
Table 3 – General condition of cold chain rooms in primary health care facilities in Wolaita zone, 2010 20
Table 4-Vaccine availability in primary health care facilities in Wolaita zone, 2010 ............................... 21
Table 5-Availability of vaccine containers and transporting materials in PHCs facilities in Wolaita zone,
2010 ...................................................................................................................................................... 22
Table 6-Availability of other necessary materials in health posts Wolaita zone, March 2010 .................. 22
Table 7- Quality assessment of Equipments and supplies in primary health care (PHC) facilities in
Wolaita zone, 2010 ................................................................................................................................ 24
Table 8-Immunization Service process as perceived by mothers/caregivers in Wolaita zone March, 2010
.............................................................................................................................................................. 25
Table 9-Status of vaccine handling and stock management in health centers, Wolaita zone, March, 2010
.............................................................................................................................................................. 26
Table 10-Status of vaccine temperature monitoring in PHCs in Wolaita zone, 2010 ............................... 27
Table 11-Condition of injection safety in PHCs in Wolaita zone, 2010 .................................................. 28
Table 12-Association between client satisfaction and predictor variables (Multiple logistic regressions)
Wolaita zone March, 2010 ..................................................................................................................... 29
Table 13-Level of knowledge among Mothers/caregivers in PHCs in Wolaita zone, March 2010 ........... 30
Table 14-Reasons given by mothers or caregivers immunizing their child in Wolaita zone, 2010 ........... 31
LIST OF FIGURES
FIGURE 1: CONCEPTUAL FRAMEWORK .......................................................................................... 5
Figure 2 Schematic representation of sampling procedure ...................................................................... 14
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ABBREVIATIONS
AD – auto disable
AEFIs -Adverse Effects Following Immunization
BCG - Bacilli Calmette-Gue´rin
DPT- Diphtheria, Pertusis and Tetanus
EDHS- Ethiopian Demographic and Health Survey
EPI- Expanded Program on Immunization
HC- Health Center
HepB- Hepatitis B
HP- Health Post
HSDP- Health Sector Development Program
MDVP- Multi Dose Vial Policy
OPV- Oral Polio Vaccine
SNNP- Southern Nations, Nationalities and Peoples
SPSS- Statistical Package for Social Sciences
TT- Tetanus Toxoid
U5- Under Five
UCI -Universal Childhood Immunization Initiative
VVM- Vaccine Vial Monitor
WHO- World Health Organization
viii
CHAPTER 1: INTRODUCTION
1.1 BACKGROUND
To save lives of millions of infants and young children dying from vaccine preventable
diseases, namely tuberculosis, tetanus, whooping cough, diphtheria, poliomyelitis and
measles, the Expanded Program on Immunization(EPI) was launched by WHO in 1974. (1)
Vaccines -which protect against disease by inducing immunity - are widely and routinely
administered around the world based on the common-sense principle that it is better to keep
people from falling ill than to treat them once they are ill. Vaccination is considered to be one of
the most cost-effective health interventions. Through vaccination one dreaded disease, Smallpox
was eradicated and poliomyelitis has been eliminated from most countries in the world.
Vaccination have an advantage in that they can be delivered with very high coverage even in the
most underserved areas, thereby preventing disease, disability and death in these marginalized
populations. (1)
All countries have national immunization programs, and in most developing countries, children
under five years old are immunized with the standard WHO-recommended vaccines that protect
against eight diseases – tuberculosis, diphtheria, tetanus (including neonatal tetanus through
immunization of mothers), pertusis, polio, measles, hepatitis B, and Hib. These vaccines are
preventing more than 2.5 million child deaths each year. This estimate is based on assumptions
of no immunization and current incidence and mortality rates in children not immunized.
Although other factors contribute to reductions in infant and child mortality rates, immunization
is believed to play a key role. (2)
Appropriate policies and strong immunization systems are needed to ensure that potent vaccines
are provided safely to every person who needs them. The main components of a well functioning
immunization system include: service delivery; capacity to maintain vaccines at the right
temperature (cold chain) and distribute them through the system in a timely manner (logistics);
monitoring and surveillance; trained health workers; and program planning and management. (3)
Despite great strides forward in vaccination development and administration throughout parts of
the world, many countries, usually the poorest, struggle with vaccinating their children. This gap
1
in immunization coverage, results from many compounding problems, such as low political
commitment on behalf of national and local governments, weak health service delivery systems,
civil unrest, and underfunding and poor management. These problems are further compounded
by relatively low levels of research and development of new vaccines to combat the predominant
diseases in the developing world. (4)
Increasing the quality of immunization services is one of the strategies to reach at general
objective of EPI in Ethiopia. According to policy guideline on EPI, improving the availability of
quality services with regard to provision of adequate and safe vaccines; provision and
maintenance of adequate cold chain, injection equipment and ensure reliable vaccine stock
control; introducing and using quality assurance methods to improve the efficiency and quality
of immunization activities at each health service level and collaboration of the National
Regulatory Authority with EPI to ensure the quality of vaccines. (5)
Infant and childhood mortality in Ethiopia are still among the highest in the world. Each year
more than one-third of a million children die from infectious disease where the prevention and
control measures are available. (6)
The Expanded Program on Immunization (EPI) was launched in Ethiopia in 1980 with the goal
of achieving universal child immunization by 1990. However, that goal remained unmet to date.
The WHO African regional office estimated that about five million children were un-immunized
for DPT3 in 2007. Thus, the challenge of meeting the EPI goal is not only limited to a few
countries, many countries in Africa are struggling to meet the immunization targets. (7)
Today, national immunization programs in developing countries are responsible for improving
access to the traditional EPI antigens and introducing new vaccines. In 2002, the EPI introduced
the Reaching Every District (RED) strategy, which focused on achieving an 80 percent coverage
rate of DTP3 in 80 percent of districts and using immunization contacts to deliver other high-
priority child health interventions. In addition to delivering vaccinations, national immunization
programs are concerned with the quality and safety of immunization through the adoption of safe
injection technologies (auto disable syringes, storage boxes, and incinerators) and proper cold
chain and vaccine stock maintenance. (8)
2
Over the last 40 years, the use of smallpox, measles, diphtheria, tetanus, pertusis, and polio
myelitis vaccines have eradicated smallpox and eliminated disease in those populations that have
(4)
achieved and sustained programs with high implementation rates. In recent years developing
countries, influenced heavily by findings in developed countries, have become increasingly
interested in assessing the quality of their health care. Outcomes have received special emphasis
as a measure of quality. Assessing outcomes has merit both as an indicator of the effectiveness of
different interventions and as part of a monitoring system directed to improving quality of care
as well as detecting its deterioration (10).
1.2 STATEMENT OF THE PROBLEM

Though the program aimed to reach all children of the world, around three million children still
die each year from vaccine preventable diseases. These deaths mostly occur in developing
countries where health systems may be weak and less able to cope with an overwhelming set of
health problem. Moreover, in the previous time much of the attention was given to increase the
EPI coverage, but now the expanded program on immunization is placing emphasis on the
quality of the service. (11, 12)
In most woredas of Ethiopia the important weakness that impede immunization program to
achieve expected goals are found to be insufficient outreach services, poor staff motivation,
infrequent in-service training and inadequate supervision, insufficient communication between
health staff and community members, inadequate monitoring systems at all levels and lack of
community participation due to lack of awareness and absence of social mobilization (13, 14)
The Ethiopian immunization program has significant problems; crippled by limited resources
and minimal capacity, poor injection safety, and a deficient cold chain. The future economic cost
to the country resulting from inadequate and unsafe vaccinations could potentially far outweigh
the level of investment required to address these issues. (14)
3
CHAPTER 2: LITERATURE REVIEW
Quality means optimizing material inputs and practitioner skill to produce health. As the Institute
of medicine defines it, quality is the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with current
professional knowledge. (15)
ELEMENTS OF HEALTH CARE QUALITY

STRUCTURAL QUALITY
Refers to stable, material characteristics (infrastructure, tools, technology) and the resources of
the organizations that provide care and the financing of care (levels of funding, staffing, payment
schemes, and incentives) Structural measures are the easiest to obtain and most commonly used
in studies of quality in developing countries. Many evaluations have revealed shortages in
medical staff, medications and other important supplies, and facilities, but material measures of
structure, perhaps surprisingly, are not causally related to better health outcomes. Although
higher technology or a more pleasant environment may be conducive to better-quality care, the
evidence indicates only a weak link between such structural elements and better health outcomes
(15).
PROCESS QUALITY
Process is the interaction between caregivers and patients during which structural inputs from the
health care system are transformed into health outcomes. It includes the patient’s activities in
seeking care and carrying it out as well as the practitioner’s activities in making a diagnosis and
recommending or implementing treatment. (15)
OUTCOME QUALITY
Outcomes can be measured in terms of health status, deaths, or disability-adjusted life years (a
measure that encompasses the morbidity and mortality of patients or groups of patients)
improvements in patient’s knowledge. Outcomes also include patient satisfaction or patient
(15)
reaction to the health care system.
4
Quality of EPI service
Socio-
STRUCTURAL PROCESS OUTCOME demographic
QUALITY QUALITY variables
QUALITY
• INJECTION SAFETY • MOTHERS

ADEQUATE • WAITING TIME CAREGIVERS
SUPPLIES AND KNOWLEDGE
• COLD CHAIN
EQUIPMENTS
MANAGEMENT
• CONSULTATION • MOTHERS/CARE
WAITING AREA • VACCINATION GIVERS
STRUCTURE ACTIVITIES SATISFACTION
• CONFIDENTIALITY
FIGURE 1: CONCEPTUAL FRAMEWORK

Before we attempt to measure the quality of care, either in general terms or in any particular site
or situation, it is necessary to come to an agreement on what the elements that constitute it are.
(16)
The measurement of quality should be based on a systemic approach that recognizes criteria
of structure, process and outcomes. In spite of different interpretations of health service quality,
key components are effectiveness, efficiency, accessibility, scientific and technical development
and the match between the availability of services and needs of the population. (17)
The three part approach to quality assessment (structure, process and outcome) is possible only
because good structure increases the likelihood of good process, and good process quality
increases the likelihood of a good out-come quality. It is necessary, therefore, to have established
such a relationship before any particular component of structure, process, or outcome can be
used to assess quality. (16)
5
Another way in which attributes of quality can be seen in health care is accessibility,
coordination and continuity, comprehensiveness, patient-centeredness, effectiveness and
efficiency. (18)
The analysis of quality in primary care quarrels that the definition and assessment of quality
must reach beyond target setting and address complexities such as the impact of socio-economic
and cultural differences and perspectives of patient groups as well as healthcare professionals,
politicians and policy makers. (19)
Quality assessment studies usually measure one of three types of outcomes: medical outcomes,
costs, and client satisfaction. For the last mentioned, clients are asked to assess not their own
(10)
health status after receiving care but their satisfaction with the services delivered. Client
satisfaction may not necessarily mean that quality is good; it may only indicate that expectations
are low. One woman in Bangladesh explained that, even though the providers behaved badly, she
has to be content. She said that they are lucky if they can get the free medicines that are provided
at the clinic. Clients may also say that they are satisfied with care because they want to please
the interviewer, worry that care may be withheld in the future, or have some cultural or other
reason to fear complaining. Many clients have limited options and have never experienced any
other standards of care. Further, educational and class differences between clients and providers
often limit clients’ ability to assess services. (20)
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 vaccinations, missed
opportunities for immunization, poor rapport with health workers and occurrence of
abscesses after vaccination. And another study in Bangladesh, Daka city indicated that only
one out of 46 clients didn’t know when to return to the next immunization (14)
Research from many countries indicates that people will use immunization services at least once
if they know what services are offered and where and when they are available. They will return if
they know when to come back, they have been treated respectfully; they have confidence that
they will receive the vaccinations that they come for. (21)
6
According to one study in Ethiopia only 66% of the cold chain equipment was found
functional at the time of the inventory. Excluding 3% of the equipment for which no record
was available, 31% of the equipment was therefore not available to support immunization
activities. (22)
In general the country data showed that mothers assessed the technical competence of
vaccinators positively. Technical competence was viewed negatively if pain was inflicted,
if bleeding, swelling or abscesses occurred, or if vaccinators broke needles or used old
ones. Personal characteristics of the vaccinators, such as age, long years of reliable service,
caste, social class, physical appearance and moral behavior, were sometimes also important
criteria. Mothers in Ethiopia expressed dissatisfaction with health workers who spent only
short periods in outreach centers. These workers were considered by the mothers to be
uninterested in their work. (23)
As one study showed in Bangladesh a significant proportion of users (34.2%) were not
satisfied with the length of time that the facilities were open to the public. About one third
(28.2%) of all users were not satisfied with the time they waited to receive care. The
average waiting time for these users was 57.1 + 4.2 min compared with 21.4 + 1.6 min for
those who were satisfied. Moreover, patients presenting for maternal care were
significantly more dissatisfied (37.6%) than clients presenting for other types of services.
(10)
A comprehensive assessment of the quality of immunization services in one major area of

Dhaka city, Bangladesh asked why mothers vaccinate their child. 35% of mothers
responded as to prevent measles, 30% to prevent TB, 25% to prevent tetanus, 19% to
prevent polio and 16% to prevent diphtheria (14)
In Ethiopia, field reports continue to indicate serious gaps in terms of distribution of

injection materials and the bundling process, use of re-sterilize able injection materials
with little capacity to ensure quality sterilization process, inadequate reporting and follow-
up of adverse effects following immunization (AEFIs) and disposal of used injection
materials. (22)
7
One survey in Ethiopia, concluded the following regarding the injection safety particularly
immunization: The results of the survey indicated that there is an urgent need for an
injection safety policy in Ethiopia to reduce the re-use of non sterile equipment, improve
sharps waste collection, and manage sharps waste appropriately. This policy should be
based upon a regular supply of auto-disabled syringes for immunization and disposable
syringes for therapeutic injections, communication activities to increase awareness in the
(22)
community and among providers, and an efficient sharps waste management strategy.
A health facility survey of child health services conducted in SNNPR in 2001 found that
79% of health centers had all the necessary EPI equipment and supplies and of the 88% of
health centers with a functioning refrigerator, only 59% reported safe vaccine temperatures
(2-80C). All vaccines were present in 89% of facilities and 6-month stock-outs were as
follows: BCG 16%, OPV 7%, DPT 14%, Measles 9%, and TT 5%. Outreach was
conducted by 98% of facilities, for an average of 7.6times/month to 8.4 communities. (24)
By 2003, it is expected that all countries will use AD syringes. The increasing demand for this
device has considerably decreased its cost. WHO and UNICEF encourage all partners involved
in immunization activities – bilateral agencies, technical institutions, EPI managers – to
“bundle” the auto-disable syringes with quality vaccines and safety boxes for collection of the
used equipment, to promote a proper disposal of wastes through incineration, and to develop
appropriate training, supervision and sensitization activities. Increasing use of AD syringes is
making an important contribution to injection safety, and all countries will have shifted to AD
syringes by 2003. This trend has gained momentum from lower costs brought about by
increasing demand and an increasing number of manufacturers. Around 50–60% of developing
countries planned to introduce auto-disable syringes in routine immunization in 2001 (80–90%
of developing countries use them in mass campaigns); it is expected that all developing countries
will use these syringes by 2003. (25)
As in many developing countries, considerable attention is needed to improve injection safety in

Ethiopia. The results of the assessment suggest that Ethiopia is facing big challenges in the area
of injection safety. For instance, one third of the injections observed during a survey were about
to be given with non-sterile equipment before a careful intervention of the field investigator. It
8
was also noted that waste disposal is deficient in the health facilities. The field investigators
observed that in 30% of the health facilities visited, the sharps used were dumped in an
unsupervised area. (25)
Study done on determinants of satisfaction with primary health care setting and services showed
that waiting area structure, explanation and consultation were important determinants of client
satisfaction in primary health care facilities. (28)
Study done on cold chain status at immunization centers in Ethiopia showed that vaccine storage
(29)
in the refrigerator was observed to be improper in 47 (74%) of the health centers and the
study done in Canada showed that 13% of vaccines were exposed to freezing during distribution
(30)
and storage , similarly the study done in two rural and one urban administrative area in
Canada indicated that there were area weakness in cold chain system in Ethiopia which could
compromise the potency of the vaccines and general quality of immunization service.
9
CHAPTER 3: SIGNIFICANCE OF THE STUDY
Persistently excessive morbidity and mortality rates in developing countries served by primary
health care systems suggest that the quality of services is inadequate. The importance of service
quality in healthcare has received some attention for over three decades now and quality
(22)
assessment has been considered as one element of quality assurance. Hence understanding
EPI service quality in structural, process and outcome dimensions will put good baseline data to
use in health service quality improvements in primary health care facility level. Efforts to
monitor and strengthen the quality of EPI activities will facilitate further decline in the numbers
of deaths and illnesses from vaccine-preventable diseases.
This survey assessed service quality of EPI using Donavedian components of service quality in
primary health care facilities of Wolaita zone. In addition EPI quality assessments have never
been studied in this zone and this study was the first to study quality of EPI in this zone.
Therefore, the study will contribute to improve quality of EPI by extracting major program
difficulty within the zone.
10
CHAPTER 4: OBJECTIVES
4.1 GENERAL OBJECTIVE
To assess the quality of EPI service in primary health care facilities in terms of structure,
process and outcome in Wolaita zone, south Ethiopia
4.2 SPECIFIC OBJECTIVES

1. To determine availability of logistics for the EPI services in PHC facilities.
2. To assess the status of cold chain management in PHC facilities
3. To observe injection safety of EPI services in PHC facilities
4. To measure mothers/caregivers satisfaction on EPI services.
5. To assess knowledge on immunization among mothers/caregivers come for EPI
service.
11
CHAPTER 5: METHODOLOGY
5.1 STUDY AREA AND PERIOD

The Southern Nations, Nationalities and Peoples’ Region has an area of 118,000 sq km. and 15.7
million people, constituting 20% of the nation’s total. It has 13 zones, eight special woredas, 133
woredas, 22 town administrations and 3,553 rural kebeles. Close 93% live in rural areas.
The Region’s potential health service coverage has grown from 28 % in 1993 (E.C.) to 74% in
June, 2008 through services provided in 13 government, four NGO, and two private hospitals,
161 health centers, 194 developing health centers, and 2,541 health posts.
Wolaita zone is one of 13 zones in the SNNP regional state. The major town of Wolaita zone,
Sodo is found 337 kilometers south to Addis Ababa. According to the 2007 census report, the
zone has total population of 1,527,908, women of reproductive age group with a population of
355,426 and U5 children with a population of 201,602. Wolaita zone health department reported
that Wolaita zone has 39 health centers and 333 health posts and with eligible children with a
population of 64,924, pregnant women of 64,289 and non pregnant of 277, 032. This study was
conducted in Wolaita zone selected primary health care facilities from March to April in 2010.
5.2 STUDY DESIGN

• Facility based cross sectional study design was used.
5.3 POPULATION
5.3.1 SOURCE POPULATION

• Mothers who utilize EPI service in the primary health care facilities in Wolaita zone.
• Primary health care facilities in Wolaita zone
5.3.2 STUDY POPULATION

Study population was the selected mothers/ care givers who come to the selected primary health
facilities during study period.
Selected PHC facilities in Wolaita zone
12
5.4 SAMPLE SIZE AND SAMPLING TECHNIQUE
First, the list of total number of health centers and health posts was obtained from zonal health
department. Accordingly there are 36 functional health centers and 333 health posts in the zone.
Health centers and health posts become functional in the last two months back from data
collection period and under construction were excluded. Simple random sampling was drawn to
include 50% (18 health centers) of total 39 health centers and 31 health posts were selected to
include 2 health posts from each health center. Eighteen health centers were decided to be taken
based on the rule of thumb in sampling for quality of care study, which states, if the number of
facilities are very large (500-1000) take a 10% sample, if it is medium size (100-500), take a 20-
30% sample and if it is very small (less than 50), take a 30-50% sample. (29) The total sample size
was allocated to 18 health centers based on client flow of previous week. And every nth client
was interviewed. N was determined from the average daily attendance of mothers who come to
EPI service which is 4. The first mother to be interviewed was determined by drawing one
number from four consecutive numbers (1, 2, 3, and 4).
13
Simple
39 HEALTH
random
sampling CENTERS
18 Health centers selected CFOPW PA

1. Bombe 18 20
2. Gesuba 17 19
3. Humbo 22 25
4. Mure 20 21
5. Tomegerera 14 16
6. Bele 18 20
7. Hanaze 17 19
8. Gale 13 15
422
9. Boditi 30 34
10. Shanto 24 27 mothers
11. Areka 27 30
12. Gununo 19 22
13. Bittana 17 19
14. Badesa 30 34
15. Hobicha 19 22
16. Soddo 41 46
17. Oydu chama 10 11
18. Dalbo 19 22
19. Total 375 422
CFOPW= Client flow of previous week
PA= Proportional allocation
Figure 2 Schematic representation of sampling procedure
Sample size of mothers/ care givers exit interview was determined by using the following
procedure.
o Significance level 95%
o Degree of error 5%
o Client satisfaction level 50% ( because no previous similar study in the area)
14
Sample size determination formula
n= (Z α/2) 2 *P (1-P)
d2
n = (1.96)2 (0.5) (0.5) = 384

(0.05)2
With 10% contingency for non-response the total sample size was 422.
5.5 DATA COLLECTION AND MANAGEMNT
5.5.1 DATA COLLECTION INSTRUMENTS

Data collection instruments were:-
• Structured questionnaire for exit interview of mothers or caregivers.
• Checklist for resource inventory
• Checklist to assess cold chain management & vaccine stock/supply management.
• Checklist to observe injection safety during service delivery
• Interview guide for district EPI coordinators
All data collection instruments were adapted from different types of literatures which are
consistent with this study.
5.5.2 DATA COLLECTORS

Data collectors were 12th grade complete students for exit interview and health officers and
nurses for health workers interview and observations. There were 10 data collectors for exit
interview and 5 data collectors for health workers interview and observations; a total of 15 data
collectors.
In summary:
• Exit interview with 405 mothers/caregivers using structured questionnaire

• Observation to assess injection safety and cold chain management
15
• In-depth interview with one EPI coordinator per district using interview guide/checklists
Table 1-Summary for all the methods used
Method Sample Instruments Unit of analysis

size
Observation
1. Injection safety 36 Observation Procedures
2. Vaccine temperature monitoring 18 checklist Health centers
In-depth interview for EPI coordinators 7 Interview -
guideline
Resource inventory
1. Health centers 18 Checklist Health centers
2. Health posts 31 Checklist Health posts
Exit interview 405 Questionnaire Individuals
5.6 STUDY VARIABLES

Dependent variable – Quality of EPI services in terms of
• Outcome (Client satisfaction)
Independent variables
o Socio-demographic variables (Mother age, Mother education, Husband education,

Residence , Occupation, Religion, Income ,and Marital status)
o Availability of equipments and supplies
o Vaccine temperature monitoring
o Safe injection practices
o Technical competence
o Confidentiality
o Consultation
o Waiting area structure
o Waiting time
o Mother knowledge
16
5.7 ANALYSIS
5.7.1 ANALYSIS OF QUANTITATIVE DATA

The quantitative data arising from the study was cleaned, coded and feed to Statistical package
for social sciences (SPSS) version 16.0. Simple frequencies were used to see the overall
distribution of the study subject with the variables under study. Odds ratio and 95% CI was used
to measure the strength of association. Univariate statistics was used to assess patterns of
responses to the questionnaire items. Chi-square (χ2) tests were used to assess differences
between categories, P-values of less than 0.05 was considered significant. Multiple logistic
regressions were done for variables found to be significant in chi-square tests and binary logistic
regressions.
5.7.2 ANALYSIS OF QUALITATIVE DATA

Qualitative data obtained from observation and in-depth interviews were identified based on their
themes, coded as to their units of meaning, and reformulated in more theoretical words.
5.8 DATA QUALITY CONTROL

The questionnaire was prepared in English and translated to Amharic language and retranslated
to English by other person who is blind to the original questionnaire to check its consistency.
Prior to the data collection, the questionnaire was pre tested in one of the health centre which
was not included in the study, and then necessary modifications were done accordingly. Two day
training was given to data collectors to ensure that they understood the data collection
instruments well so that to have quality data. There were 2 supervisors throughout the entire data
collection period so that follow the progress of data collection procedures and any other
difficulties face during data collection was solved timely and easily.
5.9 OPERATIONAL DEFINITIONS

Waiting time: The time gap between the client’s arrival at the health facility and the time the
client received service.
Vaccine e sufficient until next supply: stock contained vaccines enough for 2- 4 weeks.
Ventilated: If the room has a minimum of one window and one door.
17
Necessary EPI equipments: Refrigerator, vaccine carrier, cold box, thermometer and EPI
manual.
Client satisfaction: clients said to be satisfied by the service when score of questions under
satisfaction is greater than mean score
Adequacy of equipments and supplies: equipment or supply was assessed to be inadequate if

available in less than 60% of health facilities. It was considered fairly adequate if available in 60-
70% of the facilities and adequate if available in more than 70% of the facilities.
5.10 ETHICAL CONSIDERATIONS

A formal letter was written from ethical review committee of Jimma University College of
medical sciences and public health. The Wolaita zone health department wrote a formal letter to
the selected district health offices to make it possible to collect all necessary data.
Verbal and written consent was secured before conducting the interview and observation. For
this, a one page consent letter was attached to the cover page of each questionnaire and
observation checklist stating about the general purpose of the study and issues of confidentiality
to be discussed by interviewers before proceeding with the interview. Additionally, participants
were informed that they have a full right to refuse or discontinue participating.
5.11 DESSEMINATION PLAN OF THE STUDY FINDINGS

The findings of this study will be disseminated and presented to the College of Public Health and
Medical Science, Jimma University. And it will be presented and submitted to, SNNP Region
Health Bureau, and Wolaita Zone Health Department as to necessary. The findings will be also
disseminated to organizations that will have a contribution to improve the status of the quality of
immunization services in the region.
18
CHAPTER 6: RESULT
6.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS

Four hundred five mothers/caregivers with non response rate 4% were enrolled in this survey.
Majority 291 (72%) of respondent’s age was between 21 and 35. Mean age of the respondents’
is 25years with (SD ±5). And 181 (44.7%) were from 7-12 grade in their education. Majority of
the respondents 386 (95.3%) were married. Three fourth of the respondents (75.1%) were
Wolaita by ethnicity and 65% were protestant by religion. More than sixty four percent of the
respondents were housewives and 12.1 % were government employee. (Table 2)
Table 2–Socio-demographic characteristics of mothers/caretakers with babies under 1 year in Wolaita zone,
March, 2010
Variable Frequency Percent

Age of mothers or caregivers in years
21-35 291 71.9
15-20 104 25.7
36-45 10 2.5
Total 405 100
Educational status
Illiterate 63 15.6
Literacy education 4 1
1 – 6 grade 114 28.1
7 –12 grade 181 44.7
> 12 grade 43 10.6
Total 405 100
Marital status
Married 386 95.3
Single 17 4.2
Widowed 2 0.5
Total 405 100
Ethnicity
Wolaita 304 75.1
Amhara 60 14.8
Gofa 18 4.4
Others 23 5.7
Total 405 100
Occupation
House wives 260 64.2
Government employee 49 12.1
Students 46 11.4
Merchants 38 9.4
Others 12 3.0
Total 405 100
19
Religion
Orthodox 119 29.4
Protestant 263 64.9
Muslim 19 4.7
Catholic 4 1
Total 405 100
Residence
Urban 338 83.5
Rural 67 16.5
Total 405 100
Income
>500 322 79.5
<=500 83 20.5
Total 405 100.0
*Ethnicity others include Oromo, Tigre, Dawuro, Sidama and Gamo.
*Occupation others include NGO employee and house maids
6.2 STRUCTURAL QUALITY ASSESSMENT

6.2.1 GENERAL CONDITION OF COLD CHAIN ROOMS
All 18 health centers were observed to assess general condition cold chain rooms. As the table
shows below 12 health centers have separate cold chain rooms, cool and ventilated rooms while
the rest were found to be no separate cold chain room, cool and ventilated rooms. Some EPI
coordinators explained that they share one room for vaccination and storage of vaccines due to
lack of rooms. (Table 3)
Table 3 – General condition of cold chain rooms in primary health care facilities in Wolaita zone, 2010
Questions Number %
Does the facility have separate cold chain room?
Yes 12 66.7
No 6 33.3
Total 18 100
Ventilated room
Yes 12 66.7
No 6 33.3
Total 18 100
6.2.1 VACCINE AVAILABILITY

As one indicator of structural quality, availability of vaccines was assessed. The result showed
that 2 health centers faced polio vaccine out of stock; 3 health centers faced DPT+HepB+Hi and
TT vaccines out of stock during observation. While measles and BCG with diluents were
available within all 18 health centers observed for vaccine availability. One third (35.5%)
assessed health posts had no polio vaccines and 5(16.1%) of the health posts had no Penta
20
vaccines. Seven (22.6%) of the health posts had no measles vaccine and nine health posts (29%)
had no BCG vaccine. Around two third (63.58%) of health posts had all types vaccines. (Table
4)
Table 4-Vaccine availability in primary health care facilities in Wolaita zone, 2010
Types of vaccine Health centers Health posts
Number % Number %
Polio vaccine
Available 16 88.8 20 64.58
Not available 2 11.2 11 35.5
Total 18 100 31 100.0
BCG with diluents
Available 18 100 24 77.4
Not available 0 0 7 22.6
Total 18 100 31 100.0
Measles with diluents
Available 18 100 22 71.0
Total 18 100 31 100
DPT+HepB+Hi vaccine
26 83.9
Available 15 83.3
5 16.1
Total 18 100
TT vaccine
Available 15 83.3 25 80.6
Total 18 100 31 100.0
6.2.2 VACCINE CONTAINERS

Concerning vaccine containers (Refrigerator and vaccine carrier) of health institutions; all 18
health centers were equipped with small vaccine carriers and functional electricity refrigerators.
Three health centers have plastic ice bags and fifteen have not. Eleven out of 31 health posts
were equipped with Kerosene refrigerators and majority of the health posts had small vaccine
carriers 25 (80.6%) and ice packs 26 (83.9%) during observation.
21
Table 5-Availability of vaccine containers and transporting materials in PHCs facilities in Wolaita zone, 2010
Vaccine containers and Health centers Health posts

transporting materials
Number % Number %
Small vaccine carriers
Available 18 100 25 80.6
Total 18 100 31 100.0
Ice packs
Available 14 77.8 26 83.9
Total 18 100 31 100.0
Refrigerators
Available 18 100 11 35.5
Total 18 100 31 100.0
Some district EPI coordinators explained that because of the shortages in capital and running
costs there was no budget for training, maintenance of cold chain equipments especially
refrigerators One EPI coordinator from a district reported: “We do not have problem regarding
number of refrigerators but the main problem is no trained man power to maintain the
refrigerators.”
Some EPI coordinators tried to enlighten there is problem in transportation of vaccines to health
posts due to lack of vehicles and topographical barriers in a few districts of the zone.
6.2.3 OTHER NECESSARY RESOURCES

Other necessary materials for EPI were also assessed for availability. All eighteen health centers
had thermometers within refrigerators, AD syringes, vaccination registration books, monthly
vaccination reporting form, safety boxes, minimum of one EPI coordinator, separate service
delivery room for EPI, EPI manual, vaccine temperature monitor card and stock record books.
Three health centers had no disposable syringes, mother and children cards, TT card, daily
vaccination tally sheet and graph papers for monitoring vaccination. All assessed health posts
were equipped with AD syringes, registration books, daily vaccination sheets and monthly
vaccination report form. Twenty two (71%) health posts had no EPI manual.
All assessed health posts were equipped with AD syringes, registration books, daily vaccination
sheets and monthly vaccination report form. Twenty two (71%) health posts had no EPI manual.
Table 6-Availability of other necessary materials in health posts Wolaita zone, March 2010
22
Supplies and materials No of HPs (%) Supplies and materials No of HPs (%)
Thermometer Vaccine registration form
Available 28 (90.3) Available 25 (80.6)
Not available 3 (9.7) Not available 6 (19.4)
Total 31 (100.0) Total 31(100.0)
AD syringes Monthly vaccination reporting
Available form
31 (100)
Not available Available 31 (100)
0 (0)
Total Not available 0 (0)
31(100)
Total 31(100)
Disposable syringes File folders
Available 26 (83.9) Available 15(48.4)
Total 31 (100.0) Total 31 (100.0)
Bags File boxes
Available 16 (51.6) Available 10 (32.3)
Total 31 (100.0) Total 31 (100.0)
Registration books Graph papers for monitoring
Available vaccination
31 (100) 19 (61.3)
Not available Available
0 (0) 12 (38.7)
Total 31 (100) Not available 31 (100.0)
Total
Mothers and children cards Safety boxes
Available Available 13 (41.9)
Not available 26 (83.9) Not available 18(58.1)
Total 5 (16.1) Total 31(100.0)
31(100.0)
Tetanus vaccination card EPI manual
Available Available 9 (29.0)
Not available 0 (0) Not available 22 (71.0)
Total 31 (100) Total 31(100.0)
31 (100)
6.2.4 QUALITY ASSESSMENT OF EQUIPMENTS AND SUPPLIES

All health centers were rated as equipped with adequate vaccines of all types except that 2 health
centers and 3 health centers lacked polio and Penta vaccines respectively. Health posts were
assessed to be inadequate in terms of refrigerators in that 64.5% of the assessed health posts were
not equipped with refrigerators. (Table 7)
23
Table 7- Quality assessment of Equipments and supplies in primary health care (PHC) facilities in Wolaita
zone, 2010
Equipments and Health centers Health posts

supplies
Available Not available Quality Available Not available Quality
(%) (%) assessment (%) (%) assessment
Refrigerator 18 (100) 0 (0) Adequate 11(35.5%) 20(64.5%) Inadequate
Cold box 18 (100) 0 (0) Adequate - - -

Vaccine carrier 18 (100) 0(0) Adequate 25(80.6) 6 (19.4) Adequate
Polio vaccine 16 (88.89) 2(11.1) Adequate 20(64.58) 11(35.5) Fairly adequate
Measles vaccine 18 (100) 0 (0) Adequate 24(77.4) 7(22.6) Adequate

with its diluents
BCG with its 18 (100) 0 (0) Adequate 22 (71.0) 9 (29.0) Adequate

diluents
Penta vaccine 15 (83.4) 3 (16.6) Adequate 26 (83.9) 5 (16.1) Adequate
TT vaccine 15 (83.4) 3 (16.6) Adequate 25 (80.6) 6 (19.4) Adequate
Average (%) 94.46 5.54 Adequate 70.5% 29.5% Adequate
6.3 ASSESSMENT OF PROCESS QUALITY

6.3.1 PROCESS QUALITY PERCEIVED BY CLIENTS
Mothers were asked about process quality of EPI service in terms of technical competence of the
vaccinator, confidentiality, consultation, waiting time to get service and waiting area structure. Two
hundred forty six (60.7%) of the mothers responded as they had consultation with service provider and
252 (62.2%) of the respondents rated technical competence of the vaccinator good. Two hundred nineteen
(54.1%) of the interviewees explained that service provider was confidential about her and her baby and
202 (49.9%) had waiting time of less than or equal to 20 minutes. 192 (47.4%) were explained that they
were happy with waiting area structure of EPI service. (Table 8)
24
Table 8-Immunization Service process as perceived by mothers/caregivers in Wolaita zone March, 2010
Variables Frequency Percent

Did you have consultation with vaccinator?
Yes 246 60.7
No 159 39.7
Total 405 100.0
Technically competent
Competent 252 62.2
Not competent 153 37.8
Total 405 100.0
Vaccinator confidentiality
Confidential 219 54.1
Not confidential 186 45.9
Total 405 100.0
Waiting time
<= 20 minutes 202 49.9
>20 minutes 203 50.1
Total 405 100.0
Waiting area structure of EPI service?
Good 192 47.4
Not good 213 52.6
Total 405 100.0
6.3.2 VACCINE HANDLING AND STOCK MANAGEMENT
Fifteen (83.3%) of HCs had sufficient vaccines in their stock. Twelve HCs made vaccination
utilization according to first in first out principle. Regarding the VVMs, 15 health centers found
to be VVMs on the vaccine vials were good. In 3 health centers, VVMs showed signs of out of
use BCG and measles vaccines. And none of the health centers found using refrigerator to put
other things than vaccines. The arrangement of vaccines with in refrigerator was assessed using
standard of arrangements. Nine health centers found stored according to the standard whereas the
rest not stored vaccine according to the standard. (Table 9)
25
Table 9-Status of vaccine handling and stock management in health centers, Wolaita zone, March, 2010
Questions Number %
Is the stock of vaccine sufficient until next supply arrives?
Yes 15 83.3
No 3 16.7
Total 18 100
Is vaccine utilization made according to “first in first out”
principle?
Yes 12 66.7
No 6 33.3
Total 18 100
Are all VVMs on the vaccine vials good?
Yes 15 83.3
No 3 16.7
Total 18 100
Are the vaccines stored according to the standard?
Yes 9 50
No 9 50
Total 18 100
All district EPI coordinators explained how to estimate vaccine and supply needs of their district
during in-depth interview. Concerning vaccine wastage rate and their avoidable factors most
district EPI coordinators believe it is very difficult to avoid BCG vaccine wastage, because of
difficulty getting 20 eligible children in one day. One EPI coordinator in a district quoted that
“we have to postpone 20 mothers for one day from the week. In this case we are losing some
mothers not vaccinate their baby if they do not come on the day.”
6.3.3 VACCINE TEMPERATURE MONITORING

This study made an effort to see vaccine temperature monitoring with in selected health centers.
All HCs recorded temperature of the refrigerator least twice per day for the last three months.
All health centers had temperature charts posted on the wall of vaccination rooms. During
observation, six (33.3%) the observed health centers found with temperature in the fridge below
or above recommended range. (Table 10)
26
Table 10-Status of vaccine temperature monitoring in PHCs in Wolaita zone, 2010
S.No Questions Number %

1. Is cold chain temperature monitored and recorded at least twice per day for
the last 3 months?
Yes 18 100
No 0 0
Total 18 100
2. Temperature charts available?
Yes 18 100
No 0 0
Total 18 100
3. Temperature in the fridge normal?
Yes 12 66.7
No 6 33.3
Total 18 100
It was mentioned by most of the interviewees that there are a lot of refrigerators not functional
due to lack of maintenance. Some of the district EPI coordinators tried to explained that because
there is only electricity refrigerators, vaccine expose to above normal temperature when
electricity fluctuates.
6.3.4 INJECTION SAFETY

Regarding injection safety of vaccination, a total of 36 injection procedures were observed in 18
health centers. All health centers used AD syringes for injection but only 3 of 36 (8.34%)
observations were sterile. About 92% of the observed procedures used safety boxes to dispose
used syringes.
27
Table 11-Condition of injection safety in PHCs in Wolaita zone, 2010
S.No Questions Number %

1. Used AD syringes for injection?
Yes 36 100
No 0 0
Total 36 100
2. Is there safety box to dispose used syringes?
Yes 33 91.7
No 3 8.3
Total 36 100
3. Does the health worker see the expiry date before giving injection?
Yes 6 16.7
No 30 83.3
Total 36 100
4. Is the process of injection sterile?
Yes 3 8.3
No 33 91.7
Total 36 100
5. Does provider dispose injection supplies correctly?
Yes 31 86.1
No 5 13.3
Total 36 100
6.4 ASSESSMENT OUTCOME QUALITY
6.4.1 CLIENT SATISFACTION

One objective of this study was to assess client satisfaction of immunization service. Three
hundred forty nine (86.2%) the responded mothers were satisfied by EPI service where as fifty
six (13.2%) of the respondents were not satisfied by EPI service provided to them on the day.
Educational status of mothers, marital status, monthly income level, occupation, technical
competence of the provider, consultation, confidentiality, waiting time, explanation about
immunization and waiting area structure of EPI service were checked for any association with
client satisfaction by using multiple logistic regression. And technical competence of the
provider, consultation, confidentiality, waiting time, explanation about immunization and
waiting area structure of EPI service were found to be predictors of client satisfaction.
Mothers who had consultation with service provider were 5 times more likely to be satisfied with
service when compared with those of no consultation (OR= 5.1, 95% CI of 2.3, 11.4). Mothers
who waited less or equal to 20 minutes were 3.8 times more likely to be satisfied by service than
those waited greater than 20 minutes (OR= 3.8, 95% CI of 1.7,8.5). Mothers rated vaccinator
as confidential about them were 4.4 times more likely to be satisfied than those of rated
28
vaccinator as not confidential about them ( OR= 4.4, 95% CI of 2.0,9.6). Mothers to whom
explained about immunization by the day were 3.4 times more likely to be satisfied by the
service when compared with those of not explained about immunization (OR= 3.4, 95% CI of
1.6, 7.1). Mothers who rated vaccinator as technically competent were 5 times more likely to be
satisfied by the service than those of rated vaccinator as technically not competent ( OR= 5.1,
95% CI of 2.2, 11.8). Mothers who rated waiting area structure as good were 5 times more likely
to be satisfied than those of rated as not good ( OR= 5.2, 95% CI of 2.2, 11.1).
Table 12-Association between client satisfaction and predictor variables (Multiple logistic regressions) Wolaita
zone March, 2010
Variables Satisfied Crude OR (95% CI) Adjusted OR (95% CI)
Education of mothers
Literate 293 (72.3%) 0.7 (0.3,1.7) 0.6 (0.2, 1.7)
Illiterate 56 (13.8%) 1 1
Income level
>500birr monthly 278 (68.6%) 1.0 (0.5, 2.1) 1.9 (0.7, 4.9)
<= 500birr monthly 71 (17.5%) 1 1
Marital status
Married 332 (81.9%) 0.7 (0.1, 3.2) 0.7 (0.1, 4.0)
Not married 17 (4.1%) 1 1
Consultation with service provider
Yes 228 (56.2%) 3.9 (2.1, 7.2) 5.1(2.3, 11.4)*
No 121 (29.6%) 1 1
Waiting time
<= 20 minutes 187 (46.1%) 3.1 (1.6, 5.9) 3.8 (1.7, 8.5)*
>20minutes 162 (40%) 1 1
Technical competence
Competent 226 (55.8%) 2.1 (1.2, 3.7) 5.1 (2.2, 11.8)*
Not competent 123 (30.3%) 1 1
Vaccinator confidentiality
Confidential 203 (50.1%) 5.3 (2.7,10.4) 4.4 (2.0, 9.6)*
Not confidential 142 (35.0%) 1
Waiting area structure
Good 183 (45.1%) 5.7 (2.7,12.1) 5.2 (2.2, 11.1)*
Not good 166 (40.9%) 1
*p-value less than 0.005
6.4.2 MOTHERS’ KNOWLEDGE ON IMMUNIZATION
Mothers were asked four knowledge question regarding immunization. Three hundred twenty
eight (81%) of the responded mothers knew when to return to next immunization and 333
(82.2%) of the interviewees knew that at what age a baby completes immunization. Two hundred
ninety three mothers (72.3%) mothers knew that there vaccine given to mothers; among those
who knew that there is vaccine given to mothers 144 (49.2%) did not know that vaccine for
29
mothers is for tetanus. To determine overall knowledge level mean score was calculated to be 3.
Then mothers who scored mean and above were rated as knowledgeable and scored below mean
were rated as not knowledgeable. In this regard, 61.2% of clients were knowledgeable about
immunization and the rest were not.
Table 13-Level of knowledge among Mothers/caregivers in PHCs in Wolaita zone, March 2010
Questions Frequency Percent

Did mothers or care givers know when to return to the next immunization?
Yes 328 81
No 77 19
Total 405 100
Did mothers or caregivers know at what age a baby completes immunization
session?
Yes 333 82.2
No 72 17.8
Total 405 100
Did mothers or caregivers know that there is vaccine that is given to mothers?
Yes 293 72.3
No 112 27.7
Total 405 100
Did mothers or caregivers know the vaccine given to mothers is for tetanus?
Yes 149 50.8
No 144 49.2
Total 293 100
Overall knowledge level
Knowledgeable 248 61.2
Not knowledgeable 157 38.8
Total 405 100
All mothers/caregivers were asked to mention why they vaccinate their child. The most
commonly mentioned disease was measles (31.6%) followed by polio (24.9%). And none of the
respondents mentioned pertusis whereas 20.5% mentioned tetanus. (Table 13)
30
Table 14-Reasons given by mothers or caregivers immunizing their child in Wolaita zone, 2010
S.No Reason Percentage

1. Prevent measles 31.6
2. Prevent polio 24.9
3. Prevent tetanus 20.5
4. Prevent tuberculosis 14.6
5. Prevent diphtheria 7
6. Prevent pertusis 0
*More than 1 response was possible; hence the total is greater than 100%. Among those diseases which mothers
thought were prevented by immunization were generally good for health, HIV/AIDS, prevent from diarrheal disease
and cough.
31
CHAPTER 7: DISCUSSION
Structural quality of health facilities was assessed in terms of availability of equipments and
supplies necessary to provide immunization services. In this study, all assessed equipments and
supplies of EPI service in health centers were rated as adequate. It is higher than result of study
in south east Nigeria on quality of child health services in primary health care facilities which
rated as fairly adequate in terms of equipments and supplies. The availability of these important
equipments has the potential to encourage effective operation of immunization services because
maintenance of an effective cold chain system is important to ensure the potency of vaccines. (26)
Eighty three percent of health facilities and (64.58%) health posts observed to have all types of
vaccines in their stock and 77.7% of health centers have all the necessary EPI equipments
whereas a health facility survey of child health services conducted in SNNPR in 2001
found that 79% of health centers had all the necessary EPI equipment and supplies; all
vaccines were present in 89% of facilities. (24) A difference was found regarding vaccine
availability in health centers and health posts. This is may be due to lack of refrigerators in
health posts to store vaccines, lack of trained human power to maintain refrigerator and
topographical barriers to transport vaccines to the remote health posts. Ideally, it is
recommended that all facilities have to be equipped with all supplies and equipments
necessary to provide vaccination services. Hence findings from this study indicate that
there is space to improve regarding vaccine supplies, fridges and other equipments
necessary for vaccination in primary health care facilities especially in health posts.
Keeping vaccines at the right temperature is not an easy task, but the consequences of not doing
so can be disastrous. Once vaccine potency is lost, it cannot be regained. Damaged vaccines must
be destroyed, which can leave a country without adequate vaccine stocks and can cause serious
budget problems when the losses involve large lots and/or expensive vaccines. Children and
women who receive a vaccine that is not potent are not protected. (32)
Observation checklist was used to assess condition of cold chain management at district health
centers. One third (33%) of health centers were found to be refrigerator temperature range below
or above normal range. A research done Niassa, Mozambique showed that 69.23% health
(25)
facilities found to temperature range below above normal range. This may be due to
32
electricity fluctuation, knowledge gap and/or negligence among health workers and absence of
electricity/kerosene refrigerators.
Result of this study showed that in 50% of health centers, vaccine storage in the refrigerator was
observed to be improper. On the contrary the study done on cold chain status at immunization
centers in Ethiopia showed that vaccine storage in the refrigerator was observed to be improper
in 47 (74%) of the health centers (29) and the study done in Canada showed that 13% of vaccines
were exposed to freezing during distribution and storage (30), similarly the study done in two rural
and one urban administrative area indicated that there were area weakness in cold chain system
in Ethiopia which could compromise the potency of the vaccines and general quality of
immunization service.
As in many developing countries, considerable attention is needed to improve injection safety in

Ethiopia. It is obvious that increasing use of AD syringes is making an important contribution to
injection safety. The results of the assessment showed that all health centers use AD syringes for
injection. It is shocking that 91.6% of observed injection procedures were found to be non-
sterile. As one study in Ethiopia showed that one third of the injections observed during a survey
(25)
were found to be non-sterile. This is may be due to health workers negligence to injection
sterility.
The results in many satisfaction studies revealed that satisfaction is multi-factorial, and no one
factor could be claimed to be the sole contributor to satisfaction or dissatisfaction. Nevertheless,
some factors are more important than others in contributing to patient satisfaction. Identifying
the relative importance of the variables helps to rationalize decisions related to the improvement
of health care so that they are not limited to satisfaction rates only. (28)
Findings from multiple logistic regressions illustrated some important factors of client
satisfaction. All predictors of client satisfaction were provider related factors, which supports the
idea that some factors are more important than others in contributing to client satisfaction. In this
regard the study showed that provider related factors are more important than socio-demographic
variables in terms of client satisfaction.
33
The main predictors of client satisfaction were waiting time, provider technical competence,
consultation, explanation, confidentiality and waiting area structure. Study done on determinants
of satisfaction with primary health care setting and services showed that waiting area structure,
explanation and consultation were important determinants of client satisfaction in primary health
care facilities. This point toward it is better to focus on provider related factors to amplify client
satisfaction.
When we come to client satisfaction level by EPI service, it was showed in the result that 86.2%
of the respondents were satisfied by the service. This figure is smaller when it is compared with
other similar study done in south east Nigeria which has a client satisfaction level of
immunization services is 95.9%. This may indicate that there is difference in provider related
factors between the countries in primary health care facilities.
Research from many countries indicates that people will use immunization services at least once
if they know what services are offered and where and when they are available. They will return if
they know when to come back, they have been treated respectfully; they have confidence that
they will receive the vaccinations that they come for. (31)
Mothers’/caregivers knowledge is taken as one outcome of service quality. In assumption that

mothers/caregivers who are well informed about EPI services and vaccine preventable diseases
during facility visit will have adequate information about EPI services and positive impact
quality of the service.
As one element of knowledge, mothers/caregivers were asked if they know when to return to the
next immunization at exit of health center. Among them, 81% know when to return to the next
immunization. This result is lower when it is compared with a study done in Daka city,
Bangladesh which is 96.7% of mothers knew when to return to next immunization. All
mothers/caregivers were asked to mention why they vaccinate their child. The most commonly
mentioned disease is measles (31.6%) followed by polio (24.9%). And none of the respondents
mentioned pertusis whereas 20.5% mentioned tetanus. Similar study in Bangladesh, Dhaka city
showed that 35% of mothers responded as to prevent measles, 30% to prevent TB, 25% to
34
(14)
prevent tetanus, 19% to prevent polio and 16% to prevent diphtheria. This shows most
mothers are exactly not aware of why they vaccinate their baby. Consequently, this may
have negative impact on EPI service in that mothers will not vaccinate their babies for the
reason they don’t know.
35
CHAPTER 8: STRENGTHS AND LIMITATIONS OF THE STUDY
8.1 STRENGTHS OF THE STUDY

• Data were collected from all the three components of the program i.e. input, process and output.
• Data quality assurance mechanisms like data collectors training, supervision, and pretesting were
employed.
8.2LIMITATIONS OF THE STUDY

• As it was health institution based study information bias can be introduced in that patients
can respond in a relatively positive way fearing of being recognized.
• Possibility of observation bias can be there during observation for process of care.
• Similarly satisfied clients are relatively more likely to visit health facilities.
36
CHAPTER 9: CONCLUSION AND RECOMMENDATIONS
9.1 CONCLUSION
Even though it is essential to note that this study offers only a picture of the quality of
immunization services in PHC facilities located within Wolaita zone, there is no reason to
believe that the remarks reported in this paper are different from the situation in similar settings
in other zones of the region.
Regarding quality of EPI service in the study area the study has concluded the following:
• Majority of health centers rated as adequate in terms of equipment and supply necessary
for EPI services. But majority of health posts lack refrigerators.
• Below or above normal temperature in the fridge and inappropriate arrangement of
vaccines in the fridge were found to be the key constraints concerning vaccine handling
and cold chain management.
• Injection safety of EPI service was poor in that 91.6% of observed injection procedures
were found to be non- sterile.
• 86.2% of mothers/caregivers were satisfied by the service and shows that there is a gap
in terms of client satisfaction in Wolaita zone when compared with studies in other areas.
• 61.2% of clients were knowledgeable about immunization of mothers/caregivers were
found to be knowledgeable on immunization and vaccine preventable disease.
• Factors related with service provider were found to be important determinants of client
satisfaction.
• Although it has been argued that patients do not know what the technically acceptable
level of care is, it is agreed that dissatisfaction is an indication that services delivered are
lacking in some aspects of provider related factors.
37
9.2 RECOMMENDATIONS
District health offices / EPI coordinators
• Mothers/caregivers come for EPI services in PHCs has to be encouraged and well
informed about importance and diseases that prevented by vaccination.
• Immunization service providers need training regarding cold chain management and
vaccine handling at primary health care facilities.
• Injection safety measure has to be strengthen and training has to be given to health
workers concerning injection safety
• Short waiting time, consultation, explanation about immunization, and competency
of vaccinators has to be promoted.
To zonal health department/ Regional Health Bureau
• Health managers in the Wolaita zone and similar locales in the region should
undertake a major review of the quality of immunization services in PHC facilities,
focusing more on matters involving to process, and with particular prominence on
health worker training on cold chain management and maintenance and appropriate
vaccine temperature monitoring, and the development and implementation of
protocols for injection safety.
• Health facilities have to work strongly in the area of vaccine temperature

monitoring, since vaccines are highly sensitive to above or below recommended
temperature.
• Provider related factors such as waiting time, consultation, confidentiality, waiting

area structure and the like has to be promoted.
38
REFERRENCES
1. World health organization (WHO). Immunization service delivery and accelerated disease
control: Benefits of immunization. WHO January 2010. Available on
(http://www.who.int/immunizationdelivery/en/ Accessed on, May 30,2010)
2. World Health Organization. Ensuring vaccine quality of vaccine at country level. Guidelines
for health staff. WHO October 2002.
3. World health organization (WHO). Immunization service delivery and accelerated disease
control: Immunization systems and policy. WHO March 24, 2010. Available on
(http://www.who.int/immunization_delivery/systems_policy/en/) Accessed on May 30, 2010.
4. Dean T. Jamison, Richard G. Feachem, Malegapuru W. Makgoba and Eduard R. Bos.

Disease and Mortality in Sub-Saharan Africa, 2nd edition World Bank, 2006.
5. Federal democratic republic of Ethiopia, Ministry of Health. Expanded program on

immunization policy guideline. 2007
6. Federal ministry of health. Guidelines on the national expanded program on immunization.

FMOH Addis Ababa-Ethiopia January 2004.
7. B.Yemane. Universal Childhood Immunization: a realistic yet not achieved goal. Ethiopian
journal of Health Development. 2008;22(2)
8. Logan Brenzel, Lara J. Wolfson, Julia Fox-Rushby, Mark Miller, and Neal A. Halsey
Disease Control Priorities in Developing Countries: Vaccine-Preventable Diseases. World
Bank.1993.
9. Central Statistical Agency [Ethiopia] and ORC Macro. 2006. Ethiopia Demographic and
Health Survey 2005. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central
Statistical Agency and ORC Macro.
10. Jorge Mendoza Aldana, Helga Piechulek and Ahmed Al-Sabir. Client satisfaction and quality
of health care in rural Bangladesh. Bulletin of the World Health Organization. 2001, 79 (6).
11. Federal Democratic Republic of Ethiopia, Ministry of Health. Vaccination Service Extension
package. Addis Ababa, Ethiopia. July 2003.
39
12. Federal Democratic Republic of Ethiopia, Ministry of Health, Health and Health Related
indicator, 2007.
13. Sally Stevenson and Brenda Candries. Ethiopia National Immunization Program: Costing
and Financing Assessment. World Bank 2002.
14. Henry Perry, Robert Weierbach, Shams El-Arifeen and Iqbal Hossain, A comprehensive
assessment of the quality of immunization services in one major area of Dhaka City,
Bangladesh. Tropical Medicine and International Health. December 1998, Volume 3, no 12,
pp 981–992.
15. Peabody John W, Taguiwalo Mario M. Robalino David A. and Frenk Julio. Disease control
priorities in developing countries: Improving the Quality of Care in Developing
Countries.2006.
16. L. Gilson, M. Mangomi, E. and Mkangaa. The structural quality of Tanzanian primary health
facilities. Bulletin of World Health Organization. 1995, volume 73 (1), 105-114
17. Avedis Donavedian. The quality of care: How it can be measured? Archives of pathology
and laboratory medicine. November 1997, Vol 121, no. 11.
18. Gustavo H Marin, Martin Silverman, Carlos Sanguinetti and Ministerio de Salud. The quality
of primary care health centers in Buenos Aires, Argentina. Quality in Primary Care 2009;
17:283–7.
19. Drs. Antoni S.H. Basinski. Quality of care: what is quality and how can it be measured,
health services research. Canadian Medical Association Journal. 1992, 146 (12).
20. Alison Price. Primary care quality digests. Quality in Primary Care. 2009; 17:299–301.
21. Liz C. Creel, Justine V. Sass, and Nancy V. Yinger. Client-Centered Quality: Clients’
Perspectives and Barriers to Receiving Care. Population Council and Population Reference
Bureau. New Perspectives on Quality of Care: No. 2.
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22. P.H. Streefland, A.M.R. Chowdhury & P. Ramos-Jimenez. Quality of vaccination services
and social demand for vaccinations in Africa and Asia. Bulletin of the World Health
Organization. 1999, 77 (8).
23. UNICEF. Child Health in Ethiopia: Background Document for the National Child
Survival Conference. UNICEF Addis Ababa, Ethiopia. April, 2004.
24. Joao Carlos de, Timoteo Mavimbe and Gunnar Bjune. Cold chain management: Knowledge
and practices in primary health care facilities in Niassa, Mozambique. Ethiopian Journal of
Health Development. 2007;21(2)
25. UNICEF-WHO. Quarterly technical bulletin for managers of immunization services and
health professionals, vaccines and immunization. Issue No. 1 Vol. 1,
26. J.E. Ehiri, AE. Oyo-Ita, E. C. Anyanwu, M. M. Meremikwu and M. B. Ikpeme. Quality of
child health services in primary health care facilities in south-east Nigeria. Journal of Health
& Development. September 2004, Vol 31, no 2, 181–191.
27. Ghazi M. Al Qatari, M. Comm. H. and Dave Haran. Determinants of satisfaction with
primary health care settings and services among patients visiting primary health care centres
in Qateef, Eastern Saudi Arabia. Middle East Journal of Family Medicine. January 2008
Volume 6, Issue 1.
28. Weiss GL. Patient satisfaction with primary medical care: evaluation of socio-demographic
and pre-dispositional factors. Journal of Medical care 1998; 26(4):383-92.
29. Berhane, y. Bekele, A. Tesfaye, F. A special issue on immunization (EPI) in Ethiopia:
Acceptance coverage, and sustainability ENJ April 2000; 38 (supplement) 35-55.
30. Guidelines for child hood immunization practice. Accessed on April 26, 2006. Http:/www-
phal-aspc-9c-ca./puplicat/ccdr-rmtcc/97Vol 23sup/acs6./htm
31. United Nations agency for international development (USAID). Immunization essentials: a
practical field guide. October 2003, pp 45-46.
32. Hill P. C. et al. Risk factors for defaulting from Tb treatment: a prospective cohort study of
301 cases in Gambia. The International Journal of Tb and lung diseases.2005; 9(12) 1349-
1354
41
ANNEX 2. QUESTIONNAIRE AND CHECKLISTS
OBSERVATION CHECKLIST FOR VACCINE AND COLD CHAIN MANAGEMENT

AT DISTRICT LEVEL
Name of health facility ______________________________
Name of observer __________________________________
1. Does the facility have separate cold chain room?

a. Yes
b. No
2. Is the room ventilated?
a. Yes
b. No
3. Is the stock of vaccine sufficient until next supply arrives? (i.e. stock sufficient for 1 month
or 2 weeks) Observe if all types of vaccines are available and adequate.
a. Yes
b. No
4. Is vaccine utilization made according to “first in first out” principle? Record review
a. Yes
b. No
5. Is cold chain temperature monitored and recorded at least twice per day for the last 3
months? Record review
a. Yes
b. No
6. Has the temperature been maintained at correct level during the last 3 months including
weekends and festival days? Record review
a. Yes
b. No
7. Are all VVMs on the vaccine vials good? (Observe)
a. Yes
b. No
8. Are opened vials of freeze-dried vaccines discarded at the end of immunization sessions?
(Observe)
a. Yes
b. No
9. Are opened vials of liquid vaccines kept for the next immunization sessions? (Observe)
42
a. Yes
b. No
10. Are the vaccines stored according to the standard?
Shelf of the Standard Observed Comment on what you
refrigerator observed
Top BCG, polio and
measles
Middle TT and pentavallent
Lower Diluents
Bottom Water bottles
a. Yes
b. No
11. Are they used the refrigerator to store other things other than vaccines?
a. Yes
b. No
12. Temperature charts available?
a. Yes
b. No
13. Temperature in the fridge
a. High
b. Normal
c. Low
14. Read the thermometer before immunization?
a. Yes
b. No
43
OBSERVATION CHECKLIST OF INJECTION SAFETY
Name the health facility ____________________________________
Name of the observer ______________________________________
1. Syringe used for injection

a. AD syringe
b. Disposable
c. Re-sterilizeable syringe
2. Is there safety box to dispose used syringes?
a. Yes
b. No
3. Does the health worker see the expiry date before giving injection?
a. Yes
b. No
4. Type of waste disposal facility used for the disposal of the majority of sharps (circle only
one)
a. Open burning on the ground
b. Incinerator
c. Dumping in pit latrine or other secure pit
d. Transport for off-site treatment
5. Is the process of injection sterile?
a. Yes
b. No
6. Does the health worker use swab for skin preparation before injection is given?
a. Yes
b. No
7. Does the health worker give injection appropriately? (i.e. intradermal, intramuscular,
subcutaneous)
a. Yes
b. No
8. Does the health worker do shaking procedures before giving injection?
a. Yes
b. No
9. Does provider check and use VVM correctly?
a. Yes
b. No
10. Does provider dispose of injection supplies correctly?
a. Yes
b. No
44
EPI Resource inventory checklist for health facilities at district level
Name of Health center/health post____________________________________________
Resource inventory Available Adequate Comments on the condition of
the equipments
Vaccines Yes No Yes No
• Polio
• Measles with diluents
• BCG with diluents
• Pentavallent vaccine
• TT vaccine
Vaccine containers and Yes No Yes No
transporting materials
• Small vaccine carriers
• Plastic ice bags
• Ice packs
Thermometer
Syringes
• AD
• Disposable
Bags
Registration book
Mothers and child cards
Tetanus vaccination card
Daily vaccination tally sheet
Vaccines registration /control form
Monthly vaccination reporting form
File folders
File boxes
45
Graph papers for monitoring
vaccination
Safety boxes
Cold rooms and freezer rooms
Motorcycles
Human resource
• EPI coordinators
• Trained service providers
Steam sterilizers
Waiting rooms
Service delivery room for EPI
Have EPI manual
vaccine cold chain
monitor card,
freeze indicators
Stopwatch monitors
Stock record book/sheets
46
IN-DEPTH INTERVIEW CHECKLIST FOR DISTRICT HEALTH SYSTEM EPI
COORDINATORS
Name of health center__________________________________________________
Name of the interviewee _______________________________________________
Name of the interviewer________________________________________________
Cold chain management
1. Who is responsible for vaccine supply and distribution of your district

2. Challenge in management of cold chain management in transportation, in receiving and
distributing to health posts
3. What do suggest on record system of vaccine management?
4. Refrigerator (source of energy kerosene, gas, electricity, or solar energy)
5. How do you manage expired vaccine?
6. Communication with zonal health department and health posts (reports and supervision)?
7. Cold boxes and their management?
8. How long do you use vaccine carriers? Maximum length of time is 48 hours.
9. Do you use cold chain monitoring equipment for vaccine temperature management and
vaccine safety?
a. VVMs
b. Vaccine cold chain monitor card
c. Thermometers
d. Freeze indicators
i. Freeze watch
ii. Freeze tag
Injection safety
10. What measures do you take to have safe injection in EPI program in your district?
11. What type of syringes do you use for EPI?
Planning
12. How do you plan for immunization in your district?

13. Do you involve community in your planning?
a. Yes
b. No
14. If no why?
47
Vaccine supply estimation
15. How do you estimate vaccine and supply needs of your district?
Stock management
16. What do suggest in stock management at district level

17. What do you suggest in stock management at health facility level
18. Do you use stock cards?
a. Yes
b. No
19. If no why?
Vaccine wastage
20. What are avoidable factors in vaccine wastage?

21. What are unavoidable factors in vaccine wastage?
Human resource
22. What is vaccine wastage rate of your district/health center?
23. Adequate and trained human resource for EPI at you district?
a. Yes
b. No
24. If no why
Cold chain equipment maintenance
25. Is the refrigerator maintained as necessary

a. Yes
b. No
26. If no why
27. Is there any refrigerator out of use due to maintenance problems
a. Yes
b. No
Availability and adequacy of supplies and vaccines
28. Are there adequate vaccines and supplies?

a. Yes
b. No
29. If no, which vaccine is not available and adequate?
30. And which supply is run out of stock?
48
Budget
31. Is there adequate budget for EPI of the district?

a. For training: yes/no
b. Maintenance of cold chain equipments such as refrigerators: yes/no
c. Kerosene and any other: yes/no
32. If no why?
General
33. Generally, what do suggest on delivery of EPI service in your district/health facility?
34. What do you suggest to improve the quality of EPI service in your district/health
facility/health posts?
35. What are the main problems regarding of cold chain, injection safety, stock management,
human resource management, communication and any other activities related with
quality of EPI service in your district/health facility/health posts?
49
INTERVIEW FOR MOTHERS /CAREGIVERS
uÖ?“ É`Ï„‡ ¨<eØ ÁK¨<” ¾¡ƒvƒ ›ÑMÓKAƒ ›d×Ø KT¨p ¾}²ÒË nK SÖÃq
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’¨<::
’@ eT@ --------------------------------------- ÃvLM' ¾S×G<ƒU u²=I ¾Ö?“ É`Ïƒ ¨<eØ ÁK¨<”

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uTk`wMªƒ SÖÃp SW[ƒ KS”Ñ` Ÿ ’@ Ò` Ømƒ Åmn−‹ u=ÁdMñ Åe}— ’˜'
¾T>cÖ<˜ S[Í uS<K< uT>cØ` ¾T>Öup c=J” cU−” SÓKê ›ÁeðMÓU:: ¾ è−U
}dƒö uõLÔƒ− LÃ ¾}SW[} ’¨<:: SSKe ¾TÃðMÑ<ƒ” ØÁo ”Ç=SMc< ›ÃÑÅÆU::
”Ç=kØM õnÅ— ’ªƒ; ›− ------------ ›ÃÅKU ------------
¾Ö?“ É`Ï~ eU ----------------------------------

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k” ------------------------------------------------------
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e’-Q´v© ØÁo−‹
1. ¾ “ƒ/ ¾}”Ÿv"u= ÉT@ u›Sƒ ---------------------------

2. ¾Ií’< ÉT@ u¨^ƒ --------------------------------------------
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G. vKƒÇ`
K. ÁLÑu<
N. ¾}ó~
S. vM/T>eƒ ¾V}v†¨<
W. ¾}KÁÃ}¨< ¾T>•\
4. ¾ “ƒ/ ¾}”Ÿv"u= ¾ƒUI`ƒ Å[Í
1. ÁM}T\
2. SW[} ƒUI`ƒ
50
3. Ÿ1-6— ¡õM
4. 7-12— ¡õM
5. Ÿ12— uLÃ
5. ¾ “ƒ/¾}”Ÿv"u= ¾S•]Á x
1. Ÿ}T
2. ÑÖ`
6. GÃT•ƒ− U”É’¨<;
1. *`„Ê¡e
2. ýa’e ”ƒ
3. SeK=U
4. K?L ÃÑKê -----------------------
7. wN?[cw− U”É ’¨<;

1. ¨LÃ
2. Ñ<^Ñ@
3. c=ÇT
4. ›T^
5. K?L (ÃÑKê) ----------------------
8. Y^− U”É’¨<;
1. ¾S”ÓYƒ W^}— 2. ¾ÓM É`Ïƒ }k×]
3. ’ÒÈ 4. ¾u?ƒ Su?ƒ
5. }T] 6. K?L -------------------
9. ÁÑu<ƒ” w‰ ¾T>ÖÃp' ¾vKu?ƒ− Y^ U”É’¨<;
1. ¾S”ÓYƒ W^}— 2. ¾ÓM É`Ïƒ }k×]
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11. MÏ−” "eŸ}u< u%EL uMÏ− LÃ ¾ ¾ ¾Ö?“ ‹Ó` ’u`;
1. ›−
51
2. ›ÃÅKU
3. ›Le ¨<eU
12. ŸLÃ u}^ lØ` 11 K}Ö¾k¨< ØÁo SMe #›−$ ŸJ’' Te[Çƒ Ã‹LK<; --------------
--------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------:
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---------------------------- uÅmn
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ÁevK<;
1. ›− 2. ›ÃÅKU (›LYwU)
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-----------------------------------------------------------------::
4. ¾¡ƒvƒ ›ÑMÓKAƒ” KThhM U” SÅ[Ó ›Kuƒ wK¨< ÁevK<;

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1. -------------------------------- 5. ----------------------------------------
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4. -------------------------------- 8. ----------------------------------------
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¡ƒvƒ SŠ SSKe ”ÇKv†¨< ÃÖ¾l:: ------------------------------------
k“ƒ/XU” ƒ/¨^ƒ u%EL
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4. ›”É Ií” S<K< ¡ƒvƒ ëÊ ¾SÚ[h¨< ue”ƒ ¨` ’¨<;
-------------------------------------- u¨^ƒ
52
Good morning/ good afternoon. I would like to assess the immunization service in this
institution and would be very much interested to find out your experience today. I would like to
ask you a few questions about immunization service in this health institution and would be very
great full if you could spend a few minutes answering questions related to the service. All
information you give will be kept strictly confidential. Your participation is voluntary and you
are not obliged to answer any questions you don’t want to respond.
Do I have your permission to continue? Yes _______ No __________
Name of health institution _____________________________________________
Name or woreda _____________________________________________________
Code No____________________________________________________________
Date of Interview ____________________________________________________
Signature of interviewer_______________________________________________
53
PART I: SOCIO-DEMIOGRAPHIC CHARACTERSTICS OF MOTHERS/
CAREGIVERS
1. Age of mother/care taker in years ____________

2. Age of the child in months _________________
3. Marital status of the mother /care taker
a) Married
b) Single/never married
c) Divorced
d) Widowed
e) Separated
4. What is your education level?
a) Illiterate
b) Attended literacy education
c) From grade 1-6
d) From grade 7-12
e) 12+
5. Residence
a) Urban
b) Rural
6. What is your religion?
a) Orthodox Christian
b) Muslim
c) Protestant
d) Other specify
7. What is your ethnic Origin?
a) Wolaita
b) Gurage
c) Sidama
d) Amhara
e) Other (specify) ______________________________________
54
8. What is your occupation?
a) Government employee
b) Private enterprise employee
c) Merchant
d) House wife
e) Student
f) Other specify ___________________
9. Ask only those married, what is your spouse’s occupation?
a) Government employee
b) Private enterprise employee
c) Farmer
d) Merchant
e) Daily laborer
f) Other
10. What is the average monthly income of the household?
__________________________ in birr
11. Did your child face any health problem after taking vaccination?
a) Yes
b) No
c) I don’t remember
12. If yes to question 11, would you tell me that?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
55
PART II: CLIENT SATISFACTION
Questions responses
Are you satisfied with immunization service provided to you 1) Yes
2) No
today?
Did you have consultation with vaccinator? 1) Yes

2) No
Technically competent? 1) Competent

2) Not competent
Vaccinator confidentiality 1) Confidential

2) Not confidential
Waiting time in minutes ________________
Did the health worker explained about immunization? 1) Yes

2) No
Waiting area structure of EPI service? 1. Good

2. Not good
PART III: ACCESS TO SERVICE
1. How long does it take you to come to this health facility?

____________________________ in minutes
2. Do you think physical distance from the health facility is one barrier not to receive
immunization service?
a. Yes
b. No
3. Is there any barrier which prohibits immunization services?
________________________________________________________________
4. Ask each woman if she has suggestions for improving the vaccination services:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
56
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
PART IV: KNOWLEDGE MOTHERS ON IMMUNIZATION
1. Would you tell me the diseases that can be prevented by vaccination?

1. __________________________________________
2. __________________________________________
3. __________________________________________
4. ____ ______________________________________
5. __________________________________________
6. __________________________________________
2. Ask to see the vaccination card(s). Have the vaccination schedules of the
women and children and the rules regarding contra-indications been
observed to today?
3. Ask the women the following question: “when must you come back for
your next vaccination and/or that of your child? (Compare her answer to
the information provided on the vaccination card. If her answer does not
correspond to the nearest date indicated the answer as “No”.)
57
DECLARATION
I, the undersigned, declare that this thesis is my original work, has not been presented for a
degree in this or any other university and that all sources of materials used for the thesis have
been fully acknowledged.
Name: YIBELTAL KASSA
Signature:
Name of the institution: JIMMA UNIVERSITY, COLLEGE OF PUBLIC HEALTH AND

MEDICAL SCIENCE
Date of submission: June 22, 2010
This thesis has been submitted for examination with my approval as University advisor
Name and Signature of the first advisor: CHALLI JIRA (MPH, CHMPP, DVLDP) Professor
_______________________________________________________________________
Name and Signature of the second advisor: YOHANNES EJIGU (BSc. MSc)
_________________________________________________________________________
58

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QUALITY OF IMMUNIZATION SERVICES IN PRIMARY HEALTH

CARE FACILITIES OF WOLAITA ZONE, SOUTH ETHIOPIA

BY: YIBELTAL KASSA (Bsc.)

A thesis submitted to the Department of health planning and health service

BY: YIBELTAL KASSA (Bsc.)

ADVISORS: CHALLI JIRA (MPH, CHMPP, DVLDP) Professor

YOHANNES EJIGU (BSc. MSc)

LIST OF TABLES ................................................................................................................................ vii

LIST OF FIGURES ............................................................................................................................... vii

ABBREVIATIONS .............................................................................................................................. viii

CHAPTER 1: INTRODUCTION ............................................................................................................ 1

1.1 BACKGROUND ..................................................................................................................... 1

1.2 STATEMENT OF THE PROBLEM .............................................................................................. 3

CHAPTER 3: SIGNIFICANCE OF THE STUDY ................................................................................. 10

CHAPTER 4: OBJECTIVES ................................................................................................................. 11

4.1 GENERAL OBJECTIVE ............................................................................................................. 11

4.2 SPECIFIC OBJECTIVES ............................................................................................................ 11

5.1 STUDY AREA AND PERIOD .................................................................................................... 12

5.2 STUDY DESIGN ........................................................................................................................ 12

5.3 POPULATION ............................................................................................................................ 12

5.3.1 SOURCE POPULATION ..................................................................................................... 12

5.5 DATA COLLECTION AND MANAGEMNT ......................................................................... 15

5.7 ANALYSIS ................................................................................................................................. 17

5.7.1 ANALYSIS OF QUANTITATIVE DATA ............................................................................ 17

5.10 ETHICAL CONSIDERATIONS................................................................................................ 18

5.11 DESSEMINATION PLAN OF THE STUDY FINDINGS ......................................................... 18

CHAPTER 6: RESULT ......................................................................................................................... 19

6.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS ....................................................................... 19

6.2 STRUCTURAL QUALITY ASSESSMENT................................................................................ 20

6.2.1 GENERAL CONDITION OF COLD CHAIN ROOMS......................................................... 20

6.3.1 PROCESS QUALITY PERCEIVED BY CLIENTS .............................................................. 24

6.4.1 CLIENT SATISFACTION.................................................................................................... 28

CHAPTER 8: STRENGTHS AND LIMITATIONS OF THE STUDY .................................................. 36

8.1 STRENGTHS OF THE STUDY .................................................................................................. 36

8.2LIMITATIONS OF THE STUDY ................................................................................................ 36

CHAPTER 9: CONCLUSION AND RECOMMENDATIONS.............................................................. 37

9.1 CONCLUSION ........................................................................................................................... 37

9.2 RECOMMENDATIONS ............................................................................................................. 38

AEFIs -Adverse Effects Following Immunization

BCG - Bacilli Calmette-Gue´rin

DPT- Diphtheria, Pertusis and Tetanus

EDHS- Ethiopian Demographic and Health Survey

EPI- Expanded Program on Immunization

HC- Health Center

HP- Health Post

HSDP- Health Sector Development Program

MDVP- Multi Dose Vial Policy

OPV- Oral Polio Vaccine

SNNP- Southern Nations, Nationalities and Peoples

SPSS- Statistical Package for Social Sciences

TT- Tetanus Toxoid

U5- Under Five

UCI -Universal Childhood Immunization Initiative

VVM- Vaccine Vial Monitor

WHO- World Health Organization

1.2 STATEMENT OF THE PROBLEM

ELEMENTS OF HEALTH CARE QUALITY

• INJECTION SAFETY • MOTHERS

FIGURE 1: CONCEPTUAL FRAMEWORK