Evaluation of access and utilization of EPI services amongst children 12-23 months in Kwahu Afram Plains, Eastern region, Ghana

Introduction High vaccination coverage is required to successfully control, eliminate and eradicate vaccine preventable diseases (VPDs). In Ghana, access complete vaccination coverage is 77%. However, sustaining high coverages in island communities such as Kwahu Afram Plains North (KAPN) is still a challenge. Methods Study site and settings, an Island district. It targeted children aged 12–23 months. We used a modified WHO EPI 30 by 7 cluster sampling approach. Semi-structured questionnaires were employed for data collection. Wincosas and EpiInfo were used for data entry, management and analysis. The vaccination coverage, antigen-specific coverage calculated. The probability was set at 0.05 and the value was calculated to determine statistical significance of association. Results Of the 480 records of children analysed, fully vaccinated accounted 81.3%, partially 16.7% and not vaccinated at all 2.1%. Access was 97.3% and utilization 91.2% with Pentavalent 1-3 dropout rate of 8.8%. Coverage for specific antigens were: BCG (97.1%), OPV 1/Pentavalent 1/PCV 1/Rotarix 1 (97.3%), OPV2/ Pentavalent 2/PCV 2/Rotarix 2 (94.0%), OPV3/ Pentavalent3/PCV 3 (88.8%), MR (87.7%) and YF (87.7%). Vaccination card availability, higher educational level of mothers and lower parity levels were significantly associated (p < 0.05) positively with childhood vaccination status. Invalid doses were 21.6% of childhood total vaccinations. Key reasons accounting for non-vaccination were: distant place of immunization 34.4 % (31/90), mother being busy 14.4% (13/90), vaccine unavailability 10.0% (9/90) and fears of side reactions 8.9% (8/90). Conclusion EPI childhood vaccination coverage for January, 2016 in KAPN District was high. There is the need to focus on counteracting the reasons identified to account for vaccination failure. This would improve and sustain vaccination coverage.


Introduction
Immunization remains one of the most important public health interventions and a cost effective strategy to reduce both the morbidity and mortality associated with infectious diseases. The World Health Organization, in 1974, initiated the Expanded Programme of Immunization (EPI) as a recommendation from the World Health Assembly (WHA). This was to help member states develop an immunization and surveillance programme against Measles, Poliomyelitis, Tuberculosis, Diphtheria, Pertussis and Tetanus. EPI has led to high vaccination coverages of about 80% for the six major vaccine preventable diseases: pertussis, childhood tuberculosis, tetanus, polio, measles and diphtheria [1]. WHO reports that an estimated number of 1.5 million deaths among children under-five years occurred in 2008 from diseases that could have been prevented through routine vaccinations. These diseases were measles, diphtheria, tuberculosis, tetanus, whooping cough/pertussis, poliomyelitis, yellow fever, hepatitis B and haemophilus influenza type B infection [2]. Immunization coverage levels and trends are used to monitor the performance of immunization services locally, nationally and internationally; to guide strategies for the eradication, elimination and control of vaccinepreventable diseases [2][3][4].
In developed countries, where accurate recording of immunization and reporting of diseases is in place, most vaccine-preventable diseases are at or near record lows [5]. About three quarters of the world's child population is reached with the required vaccines, however in sub-Saharan Africa only half of the children get access to basic immunization. The worse happens in poor remote and hard to reach areas of developing countries, where one in twenty children have access to vaccination [6]. Globally, vaccination coverage is steady with 86% of children receiving DPT 3 in 2014 [7]. However, an estimated 18.7 million infants worldwide were not reached with basic vaccines in 2014. In Ghana, DPT3 administrative coverages were 93.2% and 89.9% respectively for 2014. The complete immunization coverage in Ghana in 1993 was 54.8% and this rose gradually in 2008 to 79.0% and declined to 77.3% in 2014 [8]. These unvaccinated children can build up as enough susceptible population over time and contribute to disease outbreaks. Ghana's Expanded Programme on Immunization policy recommends that children receive Bacillus Calmette-Guerin (BCG) and Oral Polio Vaccine (OPV) at birth; three doses of Pentavalent vaccine, PCV and OPV at 6, 10 and 14 weeks of age, Rotarix at 6, 10 weeks of age and measles-rubella vaccine at 9 and 18 months of age [9]. Immunizations are recorded on child health records cards obtained from the clinics. In KAPN, DPT3 administrative coverage for 2014 was 89.9%. However, a complete vaccination coverage survey has not been conducted in KAPN within the past eight years.
Administrative coverages, though with unreliable targets still records dropout of more than 10%. Reasons for this drop-out rate are still not known. Administrative data validation is a requirement by WHO.
This study therefore sought to find out the coverage rate of children aged 12 -23 months in KAPN as well as to identify the factors that influence it so as to propose recommendations for interventions and increase the immunization coverage.

Study design
A community-based cross-sectional study was conducted in which 480 mothers/guardians with children aged 12 -23 months were interviewed. The participants had to meet the inclusion criteria of being residents in the study area for a period of not less than 1 year. A two-stage cluster sampling was used. Stage one, cluster identification was done through the use of Ghana statistical service department Electoral Areas (EA) as clusters. Each EA was considered as clusters, which represented the primary sampling unit

Institutional Review Board for Noguchi Memorial Institute for
Medical Research, gave approval for the study. Permission was also sought from the District Assembly and Health Directorate. Prior consent was obtained in accordance with the ethical guidelines. All stake holders were informed about the study. Consent was sought from caregivers of selected children for the study.

Data management and analysis
The data from the field was cleaned, coded and double entered into   (Table 2).

Socio-demographic characteristics of study participants and immunization coverage
Some factors that were found to be significantly associated with immunization coverage include: level of education (p < 0.001), number of children within the family (p < 0.008) and vaccination card availability (p = 0.001) ( Table 3).

Reasons for incomplete vaccinations
The participants who could not complete (partially and not vaccinated) the routine childhood immunization schedule for their children were asked for their reasons for the vaccination failure. These high coverages reported are again supported by Osei-Sarpong's work on "Factors associated with vaccination status of children in the Ga South Municipality, 2014" [11]. Another study conducted in Gondar, Ethiopia among 12 -24 months old children reported 47.4% as fully vaccinated [12]. However, administrative coverage reported by the KAPN for BCG, Pentavalent 1, Pentavalent 3 and measles/rubella were 88.1%, 92.5%, 79.9% and 76.6% respectively [13]. Generally, these were low compared with this study. Again, the vaccination coverages were found in this study to be quite lower in sub-districts and communities that are "islands of an island"; it could be due to difficulty in rendering health care services at this area since geographical access is clearly bad with limited network.
Although KAPN has a difficult terrain and made up several island communities, the study reported good access for childhood immunizations. This was proven by the high coverage of Pentavalent 1 (97.1%). Similar findings were observed in different settings by Amanya [14] and Osei-Sarpong, 2014 [11].
Administrative coverage for 2014, was good (92.5%) but slightly lower than study findings. In general, Ghana's EPI has gained success in the area of access. As a country access coverage contradicts Wolfson et al.'s report which indicated that for developing countries only one in twenty children have access to vaccinations [6]. It must however, be noted that KAPN district's high coverage masks the poor performance of some communities and sub-districts.
A key issue that needs attention is the utilization of EPI services.
Caregivers do not report to complete vaccination schedules; example Pentavalent drop out was 8.8%. Poor utilization (high drop outs) noticed in the study is supported by KAPN's 2014 administrative data. To reduce dropout rates appointments should not only be written for mothers but in addition once any mother defaults on any of the contact vaccines, defaulter tracing in the form of home visit should be instituted. This approach will help strengthen the delivery of static immunization services [15]. On vaccination quality, card retention rate for childhood vaccinations (91.7%) were good. These childhood vaccination rates were higher than the rates recorded by the Ghana Demographic and Health Survey, 2014 (88.2%) [8]. Variables found to be significantly This was largely because place of immunization was too far (35.6%), mother was too busy (14.9%), vaccine not available (10.0%) and fears of side reactions (9.2%). These findings support several results of various studies [14,[16][17][18]. Family problems including illness of mother, unaware of the need for vaccination, unaware of the need to return for 2 nd and 3 rd doses, postponement until another time, vaccinator absent and timing of vaccination inconvenient also recorded percentages ranging from 5 to 10. KAPN district is sparsely populated especially on the "islands of island" and outreach points may indeed be far from mothers as identified.
Vaccines supply during 2014 in the district was erratic hence the finding [12]. This study was prone to recall bias since the respondents, who did not have the child health cards, were asked to recall the vaccines that were administered to their children, 1 -11 months earlier.

Conclusion
EPI childhood vaccination coverage in KAPN is high. Vaccination card availability, mother's educational level and parity were significantly associated with childhood vaccination status. EPI service quality, card retention rate for childhood vaccinations was good. Total invalid doses administered to children accounted for 21.6%. Main reasons accounting for children 12 -23 months not been vaccinated were: place of immunization too far, mother too busy and vaccine not available. Efforts to improve and sustain vaccination coverage should consider associated factors found in this study. There is also the need to focus on counteracting the reasons identified to account for incomplete vaccination. Again, to achieve optimal public health benefits, the study recommends that dropout rates are reduced through reliable vaccine supply, in-service trainings for health workers, increasing outreach points, using behaviour-change-communications strategies, client education on possible side effects/number of schedules/need to complete schedule and implementing systems for defaulter prevention and tracing.
What is known about this topic  General high vaccination coverage for childhood vaccinations (administrative).  Tables and figure   Table 1: Socio-demographic characteristics of surveyed mothers/caregivers