Executive Summary of Recent Qualitative Research on Immunisation Injections in Nepal

General Welfare Pratisthan is a Non Governmental Organisation established in 1993. It started addressing different social issues like education to girl child in Nepal, healthy environment and social health; specially STD/HIV/AIDS. This organisation is active in Central, Mid & Far West regions of Nepal for STD/HIV/AIDS prevention and control programmes through outreach to the risk behaving target populations with support from Family Health International, Save the Children (US), University of Heidelberg and Free a Child/USA.

At the request of the Ministry of Health, UNICEF Nepal office, and the USAID Nepal mission, General Welfare Pratisthan used qualitative research methods to gain insight into immunization providers and consumers' perceptions and knowledge about immunisation injection safety and actual field practices. GWP also hired a legal expert to research and document Nepali policy related to medical injections. Financial and technical support was provided by the Gates Children's Vaccine Program at PATH, Seattle, USA.

During March-May 2001, the following activities were carried during the study period;

• Altogether, 42 immunisation venues were visited and observed the practices.
  
• Key informant in-depth interviews and direct observations were conducted with 78 immunisation providers & managers.
  
• 12 Focus Group Discussions (FGDs) also were conducted with 122 mother having three years old babies.
  
• Respondents came from 16 districts across the country and represent Nepal's ethnic and geographic diversity. Of which, 16 venues were in Terai districts, 25 in Hill and 01 in mountain district.

The team discovered that, in general, there were sufficient supplies of BCG, DPT, TT, polio and measles vaccines for the expected number of clients. However, a major problem is the lack of regular supply of other required materials, especially replacement parts, syringes, needles, and fuel for sterilization. Almost every provider interviewed reported lack or insufficient supply of kerosene and this ubiquitous problem seriously compromises the safety and effectiveness of EPI throughout Nepal. Many managers and field-level staff complained of needles being repeatedly used until blunt, causing pain and distress for clients. A shortage of syringes and needles is seen across the board in EPI.

The vast majority of immunisations are given with sterilizable syringes and needles. Steam sterilizers are used extensively, though in many venues they had been broken and there were no spare parts. In those cases staff usually would try to boil injection equipment for 20-30 minutes, but even then they had problems related to lack of stoves and fuel. Respondents also reported problems maintaining cold-chain equipment; fortunately, polio Vaccine Vial Monitors (VVM) were found intact in all cases and none of them indicated excessive heat exposure.

The research team found that nearly all-managerial level participants had received adequate training and had adequate knowledge of immunisation issues and safe injection. They also had knowledge about at least some of the possible consequences of unsafe injections. The field level staff stressed that they had only received training once and that that was many years ago. They now need refresher training on immunisation, safe injection, and handling and disposal of contaminated waste. A major concern raised by both the managers and field level staff is the age of many immunisation providers. Most of the providers are above 40 years of age and many have problems related to failing vision, shaky hands, and other factors making it difficult for them to carry out their immunisation outreach duties.

In general immunisation injection equipment the team observed in use seemed to have been adequately sterilized. However, in some cases supplies of syringes and needles were inadequate and the provider did not immunise all the children with sterilized equipment. Some vaccinators reported that they dealt with this situation by changing only the needle and simply rinsing out syringes when supplies were low or clients were in hurry. Alarmingly, providers saw nothing wrong with this practice.

Disposal of contaminated medical waste, including disposable needles when used, is a serious problem. While providers are aware that they should handle and dispose of this waste carefully, it is rarely done. Instead, used supplies are tossed into a field or simply out the window of the clinic.

The research team got the general impression that providers were discouraged and immunisation safety was compromised because of lack of supportive supervision and monitoring, lack of constructive feedback, and no appreciation for their hard work.

The vast majority of mothers had a positive view of immunisation and wants to get their children immunised. Most of them lack detailed knowledge about vaccines and the diseases they prevent, however; they tend to trust provider's assurances that immunisation is necessary.

Recommendations

The managers of Nepal's Expanded Programs on Immunisation (EPI) and representatives from UNICEF, which provide major support to the EPI program, have been concerned for some time about the safety and quality of service provided by the EPI program. At the central level there is awareness of substantial logistic, technical and financial constraints. Recently, it has been documented that unsafe and unnecessary injections, along with other risky medical practices, are very common in the public sector in Nepal . Following this recent heightened awareness about these problems, especially issues related to injection safety, concerned groups were interested to investigate safety and quality in EPI at the district and field level. Qualitative research methods were selected for this study, in order to gather in-depth, descriptive information that is useful for designing intervention strategies and health education products.

Many interesting and troubling findings came out of this research. The safety and quality of service, and problems and constraints, varied according to the geographical and ethnic characteristics of each district, and there were discrepancies between the reports of managerial and field level staff. Nevertheless, there are many common trends in the data across EPI in Nepal.

A major problem in EPI is the lack of regular supply of required materials, especially replacement parts, syringes, needles, and fuel for sterilization. Almost every provider interviewed reported lack or insufficient supply of kerosene and this ubiquitous problem seriously compromises the safety and effectiveness of EPI throughout Nepal. Many managers and field-level staff complained of needles being repeatedly used until blunt, causing pain and distress for clients. A shortage of syringes and needles is seen across the board in EPI.

There was great variability in the responses regarding clients bringing their own injection equipment. Some reported that clients rarely bring them, and that if they do, providers will not use this equipment. Others reported that clients often bring disposable with them, as EPI equipment is not trusted, and that the staff are obliged to use this equipment. Others reported that they encourage clients to bring their own equipment, and some even reported that clients are required to provide their own equipment, as sterilization is not possible. It was frequently reported that pregnant women must provide their own injection equipment for TT vaccines. No providers knew what happens with clients' own injection equipment, with regard to re-use or disposal.

The managerial level respondents nearly all received adequate training, and therefore had adequate knowledge on immunisation issues and safe injection practices. Nearly all were well aware of the risks of unsafe injections, both to consumers and providers, and most were aware of the risks of improper disposal. Managers reported needing training on disposal management. Most field staff could adequately define a safe injection, and had knowledge about at least some of the possible consequences of unsafe injections.

However, the field-level staff repeatedly stressed that they had only received training once, often many years ago, and they badly need refresher training on immunisation and safe injections. It was frequently reported that there is a shortage of well-trained staff. No field staff had received training on disposal, and as peons carry out the brunt of disposal, all staff, including peons, requires training on safe disposal practices. A major problem, identified both by mangers and field level staff, is the age of field staff. Many are substantially above 40, and problems such as poor vision, shaking hands and general lack of strength and vigor compromise their ability to carry out their duties, especially immunisation outreach sessions. Managers requested a retirement provision, so new, younger staff could replace old staff. In some centers peons (helpers) and other untrained staff are providing immunizations. Although this is not officially recognized, nor condoned by EPI regulations, it is a reality, and therefore these providers require training.

The reports about sterilization in EPI were mixed. On the one hand, nearly all managers and field-level staff are aware of proper, or at least acceptable, procedures. Steam sterilizers are in widespread use, and most report boiling equipment for 20-30 minutes. On the other hand, substantial constraints to proper sterilization are common throughout EPI, namely lack of replacement parts for old and broken equipment, lack of stoves and especially lack of fuel for sterilization. Usually firewood must be foraged or solicited from communities, especially for outreach sessions. Timers for sterilization are very often lacking, and TST stickers have hardly reached any immunisation sites-we did not see any during our observations.

Most providers report following safety procedures during immunisation. Many providers know they should not touch sensitive parts of the syringes and needles with their hands, but they often touch them anyway because of carelessness. Thus training on safe handling is urgently required. The great majority of immunisation sessions, both outreach sessions and those in Health Posts (HP's) and Sub Health Posts (SHP's), lack of running water, so hand washing is very rare.

Alarmingly, some field-level staff reported that they change the needle and simply wash the syringe when supplies are low or clients are in a hurry. These providers saw nothing wrong with this practice.

Cold-chain maintenance is badly needed, and thermometers and electricity provisions are often lacking. Many field-level staff requested training on cold-chain maintenance. From observations, the cold-chain was usually unsatisfactorily maintained. Usually ice was found melted in the pack during the session, except very few exceptions. Some providers reported broken refrigerators. Many managers and field-level staff requested additional cold-chain capacity, for each HP's and SHP's. Field-staff very frequently reported difficulties in maintaining the cold-chain, especially when long distances had to be covered and in the hot season.

Most managers and field-level staff are aware of acceptable disposal procedure, i.e. to burn waste, and/or to bury it in a pit. But most report that disposal is a major problem. Especially at the health post and sub-health post level, improper disposal is very common. In our observations, the surroundings of some venues were littered with vials, syringes and needles. We also observed that the needle would be bent and the syringe (used for TT vaccine) would be thrown out the window or door. Mothers reported during FGDs that in most centers disposal systems are unsafe and risky. Many providers expressed concern that children are playing with disposed materials. In outreach sessions, the vaccinator is responsible and otherwise peons generally are carrying out disposal and are responsible. Clear regulations regarding disposal are lacking, and mechanisms for management, supervision and enforcement of disposal procedures are urgently required. Training at all levels, from managers to peons, would be the most essential provision. Optimally, each center should be equipped with an incinerator, so disposal items may be burnt quickly and easily each day.

From our observations, providers usually spoke with clients about immunisation or other health topics in a congenial atmosphere. But in some cases when clients asked questions the provider was too arrogant or too busy to answer. Mothers reported in FGDs that most immunisation centers lack enough staff, and therefore have a disorganized and hectic discussion atmosphere. Mothers feel there are very few appropriate interactions between staff and clients with regard to health issues and vaccines.

A general impression from managers and field-level staff is that providers are becoming less serious and less committed towards their work because of a lack of monitoring, follow-up, feedback, and appreciation for hard work.

Solutions mentioned included offering incentives for fieldwork and rewards for good work. Some respondents mentioned that management training from NGOs had had a good impact in the past.

Most mothers lack knowledge about the different types of vaccines and the diseases they prevent, but they follow instructions of health workers, whom they trust. Most mothers have a positive view of immunisation, and want to get their children immunised, but many face substantial difficulties in attending outreach sessions, especially due to distance, their home workload, and lack of support from some elders. Some mothers have a negative view of vaccines, as do some elders, and prefer to use herbal medicines and faith healers when health problems arise. It is therefore important to give accurate information about the benefits, advantages and importance of vaccines.

In order to improve public participation in immunisation, providers emphasized those female health volunteers and mother's groups have contributed in the past, and suggested mobilising them by providing training, transportation, field allowances, and necessary materials. Also recommended was orientation for and mobilisation of social workers, young volunteers, local opinion leaders and VDC members (particularly the VDC secretary).

For improving timeliness and coverage, providers recommend that people need to be educated about the advantages of vaccines, and the disadvantages of not receiving vaccines. Communities need to be better informed about the schedule of vaccines. Many respondents mentioned that school education programs would be beneficial. Many providers said that illiterate, poor and marginal people need to be motivated with programs suitable for them. With regard to public education, providers suggest using street-dramas, role-plays, slide shows and video films based on local scenarios, in local languages.

There is a severe policy gap in Nepal vis-à-vis injection safety. In light of the present and potential health hazard linked to improper injection practices, it is crucial to formulate clear and enforceable policies aimed at reducing cross-infection through injection and other small, invasive procedures. HMG/Nepal should constitute a policy formulation team of experts of this field and consider their recommendations. Specific medical procedures should be regulated through the existing Medical Council Act and Rules as well as through the nursing Council Act 2052.

Similarly, General Welfare Pratisthan had a study on public perceptions on injections and private injection practices in central Nepal with support from Bill and Melinda gate's Children Vaccine programs at PATH.

The study carried out from March -August, 2000T had the following activities;

• All together at least 105 In-depth interviews with the providers and the injection consumer
  
• All together at least 16 Focus Group Discussions with injection consumers
  
• All together at least 30 Secret Shopping at private injection practitioners' shops

The following were the major findings in brief;