Quality of Vaccination Services and Social Demand for Vaccinations in Africa and Asia
Streefland, P. H., Chowdhury, A. M. R., Ramos-Jimenez, P., Bulletin of the World Health Organization
Voir page 729 le resume en francais. En la pagina 730 figura un resumen en espanol.
The induction of an immune response to infectious diseases by vaccination has become a widely applied and accepted public health intervention (1, 2). For immunization to be effective as a long-term global childhood disease control strategy it is essential that parents continue to present their children for vaccination. Where childhood vaccination proceeds on the basis of parental consent, as in most societies, it is essential that parents trust the quality of the service on offer. Recent studies in Africa and Asia have shown that mothers present their children for vaccination with a view to preventing illness, boosting their general health, and/or reducing the severity of possible illness in the future. The decision to attend vaccination sessions is also influenced by the quality of services as perceived and experienced.
An international comparative research project[a] was initiated in Africa, Asia, Europe, and the USA in 1994 to improve the coverage and sustainability of vaccination programmes through a better understanding of their social and cultural aspects. The work was carried out by national research teams in Bangladesh, Ethiopia, India, Malawi, and the Philippines, and three transnational investigations were conducted on the following topics:
-- immunization and the state;
-- global programming and technology development;
-- social demand for vaccinations in relation to the quality of vaccination services.
Each of the country studies developed its own protocol, but there were strong similarities between the studies in terms of their objectives and methodology. The instruments outlined below were used to strengthen coherence between studies.
* Researchers from all the teams attended a course on medical anthropology and another on the analysis of qualitative data, and participated in a monitoring workshop that covered sampling and data collection methods.
* A master checklist of research questions and indicators was developed so that all the country studies included a framework of similar questions in addition to those pertinent to conditions in particular countries.
* Several countries received technical support for improving the quality of data collection and analysis.
The results of the studies in Africa and Asia reported in the present paper indicate that the quality of vaccination services still leaves much to be desired. The paper also provides information on parents' perceptions and on the effects of negative perceptions on the acceptance of vaccination. A considerable amount of research has been done on the quality of health care and family spacing services, and various indicators have been suggested (3-5). The framework used below was adapted for the analysis of vaccination services. The following broad aspects of the provision of vaccination were studied in order to assess technical quality:
-- technical competence of health workers directly involved in giving vaccinations;
-- information provided by health workers to clients;
-- vaccine administration;
-- follow-up and continuity mechanisms;
-- linkages and coordination between various providers in particular areas.
The country studies looked into the perceptions and experiences of users, usually mothers, concerning the quality of care in vaccination delivery, with regard to:
-- technical competence;
-- information provided;
-- access to services;
-- interpersonal relations between clients and vaccinators;
The researchers in the country studies collected quantitative information, particularly coverage data, by studying records and sometimes making home visits. They obtained qualitative data by observing vaccination sessions, conducting in-depth and semi-structured interviews with parents, health workers and key informants, and organizing focus group discussions. …