Ethiopian Public Health Association, P.O. Box 7117, Addis Ababa, Ethiopia.
Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.
Infect Dis Poverty. 2018 Nov 30;7(1):119. doi: 10.1186/s40249-018-0502-8.
Strong scientific evidence is needed to support low-income countries in building effective and sustainable immunization programs and proactively engaging in global vaccine development and implementation initiatives. This study aimed to implement and evaluate the effectiveness of system-wide continuous quality improvement (CQI) interventions to improve national immunization programme performance in Ethiopia.
The study used a prospective, quasi-experimental design with an interrupted time-series analysis to collect data from 781 government health sectors (556 healthcare facilities, 196 district health offices, and 29 zonal health departments) selected from developing and emerging regions in Ethiopia. Procedures included baseline quality assessment of immunization programme and services using structured checklists; immunization systems strengthening using onsite technical support, training, and supportive supervision interventions in a Plan-Do-Check-Act cycle over 12 months; and collection and analysis of data at baseline and at the 6th and 12th month of interventions using statistical process control and the t-test. Outcome measures were the coverage of the vaccines pentavalent 3, measles, Bacillus Calmette-Guérin vaccine (BCG), Pneumococcal Conjugate Vaccine (PCV), as well as full vaccination status; while process measures were changes in human resources, planning, service delivery, logistics and supply, documentation, coordination and collaboration, and monitoring and evaluation. Analysis and interpretation of data adhered to SQUIRE 2.0 guidelines.
Prior to the interventions, vaccination coverage was low and all seven process indicators had an aggregate score of below 50%, with significant differences in performance at healthcare facility level between developing and emerging regions (P = 0.0001). Following the interventions, vaccination coverage improved significantly from 63.6% at baseline to 79.3% for pentavalent (P = 0.0001), 62.5 to 72.8% for measles (P = 0.009), 62.4 to 73.5% for BCG (P = 0.0001), 65.3 to 81.0% for PCV (P = 0.02), and insignificantly from 56.2 to 74.2% for full vaccination. All seven process indicators scored above 75% in all regions, with no significant differences found in performance between developing and emerging regions.
The CQI interventions improved immunization capacity and vaccination coverage in Ethiopia, where the unstable transmission patterns and intensity of infectious diseases necessitate for a state of readiness of the health system at all times. The approach was found to empower zone, district, and facility-level health sectors to exercise accountability and share ownership of immunization outcomes. While universal approaches can improve routine immunization, local innovative interventions that target local problems and dynamics are also necessary to achieve optimal coverage.
需要强有力的科学证据来支持低收入国家建立有效的和可持续的免疫规划，并积极参与全球疫苗开发和实施倡议。本研究旨在实施和评估系统范围的持续质量改进（CQI）干预措施，以提高埃塞俄比亚国家免疫规划的绩效。
该研究采用前瞻性、准实验设计，采用中断时间序列分析，从埃塞俄比亚发展中和新兴地区选择了 781 个政府卫生部门（556 个医疗保健机构、196 个区卫生办公室和 29 个区卫生部门），收集数据。程序包括使用结构化检查表对免疫规划和服务进行基线质量评估；在 12 个月内使用现场技术支持、培训和支持性监督干预措施，在计划-执行-检查-行动周期中加强免疫系统；并在干预的第 6 个月和第 12 个月使用统计过程控制和 t 检验收集和分析数据。结果衡量指标是五联疫苗 3、麻疹、卡介苗（BCG）、肺炎球菌结合疫苗（PCV）以及完全接种疫苗的覆盖率；而过程衡量指标是人力资源、规划、服务提供、后勤和供应、文件记录、协调与合作以及监测和评估的变化。数据的分析和解释符合 SQUIRE 2.0 指南。
在干预之前，疫苗接种覆盖率较低，所有七个过程指标的综合得分均低于 50%，发展中和新兴地区之间在医疗保健机构层面的表现存在显著差异（P=0.0001）。干预后，五联疫苗的接种覆盖率从基线的 63.6%显著提高到 79.3%（P=0.0001），麻疹从 62.5%提高到 72.8%（P=0.009），BCG 从 62.4%提高到 73.5%（P=0.0001），PCV 从 65.3%提高到 81.0%（P=0.02），完全接种疫苗的覆盖率从 56.2%提高到 74.2%，但差异不显著。所有七个过程指标在所有地区的得分均高于 75%，在发展中和新兴地区之间未发现表现差异。
CQI 干预措施提高了埃塞俄比亚的免疫能力和疫苗接种覆盖率，在那里，不稳定的传染病传播模式和强度需要卫生系统随时保持准备状态。该方法被发现使区、区和设施级别的卫生部门能够承担责任，并对免疫结果拥有共同的所有权。虽然通用方法可以提高常规免疫，但也需要针对当地问题和动态的本地创新干预措施，以实现最佳覆盖率。
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