IOCH Immunization and Other Child Health Project

Vaccination coverage and health seeking

behavior of the slum residents of the Mirpur

area of Zone 8 of Dhaka City Corporation - March 2002

Survey Report No. 61

This survey was conducted by IOCH, a project of Ma~gmtIent Sciences for Health. funded by USAlD under AID contract No. HRN-I-Ol-SM)OO33-00. Task Order No. 01

Progress Tower (Level 3) House 1. Road 23, Gulshan 1. Dhaka 121 2. Bangladesh

Tel: 881361 1 Fax: 880-2-8826229

E-mail: ioch@citechw.net

June 2002

Table of Contents

List of Tables and List of Charts

Acronyms

Terminology

Executive Summary

Objectives

Methodology and its Limitations

Results

Routine immunization coverage levels of children

Coverage levels of NID campaign

Routine lT immunization coverage levels of women

Health care practices and health care seeking behavior in char areas

Conclusions

Reference and Resource Mataids

Annexures Annex A: EPI Cluster Survcy d d p (exUacS from an article written by Anlbony G Turner.

Robert J Magnani and MohDrmod Shuaib) Annex B: Illusbation ofwhen ciddral surveyed tius1 k a m e el~gible for diffmnl vscclmr Annex C: List of wlecud clunm

Acknowledgements

GK Survey Report

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List of Tables

Table 1: Routine immunization coverage levels of the children

Table 2: Routine immunktion coverage levels by sex of the child

Table 3: Reasons for non-immunization and partial immunization of the childrem

Table 4: Reasons for non-immunization and partial immunization for TT of the women

Table 5: Illness and expendihue status of under five children

List of Charts

Chart 1: Immunization coverage among children less than I2 months old

Chart 2: Dropout rates for childhood immunization

Chart 3: Source of information of routine childhood immunization

Chart 4: Routine immunization coverage levels for TT of the women (1 5-49 years)

Chart 5: Dropout rates for TT immunization

Chart 6: Source of information and motivation for last dose of routine TT immunization

Chart 7: Providers of routine childhood and TT immunization

Chart 8: Coverage of OPV and Vitamin A during the seventh NID campaign

Chart 9: Reasons for not receiving OPV during the seventh NID campaign

Chart 10: Sources of information for seventh NID campaign (2nd round)

GK Survey Report

ADB: ANC: CC: CHW: DCC : D m EC: EPI: ESP: GK: HPSP: IOCH: LGRD: MCH-FP: M O W : OPV: PCC: PNC: Tl-: UCHP: URIP: UPHCP:

Acronyms

Asian Development Bank Antenatal Cam City Corporations Community Health Worker Dhaka City Corporation Diphtheri4 Pertussis, Tetanus vaccine European Commission Expanded Program on Immunization Essential Services Package Gonoshasthaya Kendm Health Population Senices Program Immunization and Other Child Health Project (USAIDMSH) Ministry of Local Government and Rural Development Mother and Child Health - Family Planning Ministry ofHealth and Family Welfare Oral Polio Vaccine Peripheral Community Centers Postnatal Care Tetanus Toxoid Urban Community Health Program (GK) Urban Family Health Partnership (USAID/JSI) Urban Primary Health Care Project (ADB)

GK Survey Report

Terminology

This provides the meaning of some of the more technical terms related to coverage and used in this report and a brief explanation of their use.

By card: An immunization given to a child is termed as by card if the date of the dose is enteral on an immunization card. Only doses recorded by card are treated as valid data in this survey.

By history: Immunization history collected h m a parent's mall is termed as by history. Often no date will be mentioned. This information is only included in crude data

Crude coverage rate is calculated h m the doses recorded by card and/or by history. It is not ascertained whether the doses were given at the correct age and/or following the correct intaval (where applicable). Crude data however, helps us to understand how much additional coverage could be achieved if all vaccines were given at the optimum age for the child and following the optimum interval. It also provides useful information on access to the EPI program and on the operational aspects of the provision of health services.

Valid coverage rate is calculated h m the vaccinations recorded by card. Valid data includes only the doses of vaccines that were given after the minimum date of eligibility andlor after the minimum interval necessary to be effective and to protect the child. There is no maximum interval for a dose and therefore a dose administered after 52 weeks is still regarded as valid. By comparing crude coverage with valid coverage data of any particular antigen, o w can determine how much coverage was lost due to the inability to give vaccine at the appropriate time.

Invalid doses are those administered at the wrong age and/or at the wrong interval. Dases adrninisterod before the minimum age in the case of DPT'IPolio I' doses and Measles vaccine or with less than four weeks interval in the case of DPT or Polio vaccines are classified as "invalid doses.

The criteria for a valid dare used in this survey is the criteria recognized by the Bangladesh EP1 program: minimum age for DPT'IPolio I" dose - 6 weeks old; minimum DPTlPolio interval - 4 weeks; minimum age for Measles vaccine - 38 weeks old.

Program access is measured by the percentage of children surveyed who received DPT I * dose (crude data - by card and history) in the routine immunization session.

Fully immunized means the child has received all the doses it requires (BCG, OPV 1-3, DPT I - 3 and measles).

Missed Opportunity refen to a visit of a child to a vaccinalon center for a dose that he received. However at that time he was also eligible for another dose of antigen that he did not receive. if the missed dose was provided at a later date, it is a corrected mrssed opponuniry. If not, it is an uncorrected mirsed opporluniy.

Executive Summary

Background

Dhaka and its suburbs are one of the great tnetropolises of the world with probably 10 million people. The 200 1 Census estimated the population of the 10 mnes of Dhaka City Corporabon at 5.3 million. Since May 1999 lOCH has been working in DCC with all the adom involved in polio eradication and in the strengthening of routine immunization savices. Its Monitoring and Evaluation Unit has conducted many vaccination covetage surveys of Dhaka City C o w o n either as a whole or of its slums. In March 2002 IOCH took the opportunity of an evaluation of the activities of Gowshastyo Kendra (GK) in the Mvpur a& of the Zone 8 of DCC to &atate a vaccination coverage and a health-seeking behavior survey of the slum residents living around the health clinics operated by GK.

Undastanding the exact of the EPI activities of GK in Zone 8 has been a bit challenging. It seems that on July 2 2000 the AH0 of Zone 8 granted permission to provide EPI tarice a week at a tixed clinic in Ward 3, Road 8. House 7. However the Zonal EPI supervisor acknowledged that GK provide EPI at 13 sites in 5 di5-t wards (without official written authorization). Vaccine is obtained fbm the Zonal office for the authorized clinic but is lata broadcasted to the other satellite clinic as well. This situation is not unusual and illustmes the realities of the EPI xene in DCC ("free market" or '%Id west" d q e d m g on the interpretation). But the bottom line is that GK operates 13 satellite sites and one fixed clinic that all provide vaccination services.

Objectives

The principal objectives of the m e y were: a) to assess the levels of routine immunization coverage of children (12-23 months) and to 6nd out the reasons for non-immlmization and partial immunization, b) to assess the levels of 'IT immunization coverage in women of child bearing age (1 5-49 years) regardless of their marital status and to find out the reasons for non-immunization and partial immunization, C) to assess the coverage levels of OPV and Vitamin A during the firsi round of the lOrh NID campaign conducted in January 2002 and find out the reasons for non-immunization. d) to explore the health-seeking behavior of the residents of the slum arras close to the GK clinics.

Coverage Levels for the routine immuuization of slum children of tbe Mirpur a m

Access: 93% of the children received at least one dose of antigen @PT 1st dose in this case) h m routine immunization sessions based on crude data (card plus history). Howwa 6% of the children surveyed did not receive any immunization.

Crude coverage between 12-23 month: 94% children m . v e d BCG, 80 % received three doses of OPV and DPT and 72 % reseived measles vaccine.

GK Survey Report

Valid coverage between 12-23 months: 94 % children received BCG, 73 % received three doses of OPV and DPT and 62 % received measles vaccine.

Valid coverage by I2 months: 94% children received BCG, 75% received three valid doses of OPV and DPT and 72% received a valid dose of measles vaccine. 57% of the children received all valid doses by 12 months of age.

Initial access to immuniution servica is good in the s l n m of Mirpnr. Overall crude coverage is close to national average. Valid coverage and valid coverage by 12 months are above national figures. However there is room for improvement and the dropout rate should be reduced.

Drop out was found to be 14 % for DPTI and DPT3 and 22 % for DPTI-measles.

Availabiliv of cards was 44% and the retention rate (number of children having a card among those who were ever given a card) was 47%. 94% of the children were given a card at any time.

Invalid dater (assessed among card-holders) were found low for BCG, DPTI and measles. For DPT 2 and DFT3 the gap was of 5 percentage points in each case reflecting early dases.

Gender dtjierences were found important, starting with initial access and then increasing because of the dropout and because of the lower attention paid to the girls for scruning for early doses. Overall the coverage of girls for all valid antigens at 12 months is 51% (versus 63% for boys). This lack of attention to girls is surprising in a context of NGOs (all claiming to make women's health a priority) playing a major role in the provision of EPI.

Missed oppominitiesfor immwrizalion accounted for 4% for BCG but 7% for DPTl and around U3 % for other doses. Most of the missed opportunities were corrected later on.

Source of immunizcrlion:

Two types of analysis of the source of vaccination of DPTl were undatalen. one only h n the childrm who hsd a card and the other h r n the cards and history collated (reliably) born the mothers of the children. From the cards available at the time of the survey the following distribution was obtained: Radda Bamen 7 1 %, other NGOs 16%, GOB 7% GK 2%. any hospital 3% and home 1%. From the cards and history the disaibution varies a bit: Radda Barnen 5704 other NGOs 24% GOB 10%. GK 3%. home 2% and hospital and private clinics 3 and I% respectively.

What is the context in which the apparently small contribution of GK to the immunization of the children in Mupur should be undmtood? Firsl the survey, by sampling children aged 12-23 months in March 2002 analyze the activities that took place when they w m lm than 12 montbs, i.e. between March 2000 and March 2001. GK started to work in the area in May 2000 and its vaccination activities started in September 2000. Since GK is competing with other NGOs that have been working for many years in the same area it is not surprising that the fust months of GK vaccination activities had a poor yield. Geographical distance was not a significant f a r in

the low usage rate as 40% of the people surveyed were found to live 5 minutes or less on foot from a GK clinic and 86% at 10 minutes or less. IOCH staff a . the distances by walking themselves.

Reasons for non-immunizdion and partial immunization of children: The main reasons for non- immunization wcre the lack of knowledge of the parentslcamakers about the importance of immunization and the sickness of either the child or of hisher mother. The main reasons for partial immunization were: the sickness of the child (33%) who either did not go to the vaccination m t e r or was denied the vaccination on account of the illness; igwraace that a subsequent dose was needed (24% of cases).

Knowledge of (he rig& number of required v i t h forfull immunization. 6 1 % of the families knew the right answer. Having a vaccination card at bome did not make any difference in the knowledge. However none of the families having never received a card lmcw the correct answer.

Covenge lweh for the Routine lT immuukatiou of women 83 % of the women of childbearing age (1 549 years) received one dose of m, 8 1 % a 2nd dose of IT and 37% the five doses of lT vaccine. 17 % never received any immunization. Never immunized age-group distribution does not show on age related cluster effect for the 20-25 age group. Young and older women appear to receive less attention.

Sources of immunization The distribution by providers show that Radda Barnen provided 57% of the l T I doses, GOB 25%. other NGOs 8%, hospitals and publidprivate clinics 7O% and GK 2%. The low contribution of GK could be explained by the fact that the majority of eligible women has already b m vaccinated and that only the young women entering the cohort are potential targets of GK activities.

Reasons for non-irnmunizalion and partial irnmunircltion of m e n : The major reason cited for non-immunization was that the women do not feel any need for immunization (68Y.). 24% expressed fear of injections. Whereas the major reasons cited for partial immunization were ignorance of the need for subsequent doses either in g d or beyond 2 or 3 dous. 22% claimed that the local health worker informed there that only 23 doses were needed.

Covenge lweb for the fint round of the lo* MD Campaign 92 % of the 0-5 year children received OPV on the day of the lorn NIDs and an additional 3% during the subsequent child-Whild days. 80% only of the eligible childm received Vitamin A. The analysis took into account the eligibility of the children at the time of NlDs. IOCH OSO and PEF did not have explanations for this finding that conflicts with the 95% figure officially reported by DCC.

39 % of the people knew about the NIDs from a health workerlvolun~. 39% from a relativdneighbor, 27% from the TV, 4% from radio. 34% from miking. These categories are not exclusive.

GK Survey Report

Access to health care and hulth-seeking behavior

a) Morbidity In the 2 weeks pmeding the survey (late February) 137 people were sick 63% suffered lium common cold with fever, 22% of diarrhddysentery and 15% from other causes. The age distribution of the cases (not the attack rate) by disease shows that the less than 5 years represented 65% of the common cold and 59% of the diarrhddysentery group.

b) Physical access to health care Among the private health can providers been called upon 36% less than a quarter mile h m people, 61% less than half-mile and 88% less than a mile and a half. The mean distance was .83 mile. 33% of the pharmacists live within a quarter of a mile and all within a mile and a half. The mean distance was .7 1 mile. 25% of the people who consulted a GOB health facility live within a quarter mile of it and 75% within a mile.

c) Health Care seeking behavior

All families were asked where do they normally go for treatment if they seek treatment. Pharmacists came first (57%). then private doctors (24%). Radda Bamen (8%). various NGOs between 2 and 4% and URIP and GK last (.7%). However when the families which had a member sick in the last 2 weeks were asked where they went, the relative importance of the above categories changed somehow: pharmacists (51%). private doctors (14%). homeopaths (7%). MBBS and Mary Stopes (6%) while Radda Bamen and GOB were used in job of the cases. GK remains at the same level (1%).

There are some gender differences in the use of practitioners. No differrnce was noted for the use of pharmacies, private doctors and Marie Stopes's clinic. Male (86%) do- among the users of homeowh, MBBS doctors (75%). GOB facilities (67%). Kabirai (all) and GK (the - . only case). women p f e r to use ~adda en (67%)and other N&.

It should be mentioned that not everyone consults in case of illness: only 63% in case of common coldlfeva and diarrhddyseatery. There was no gender differrnce. For other ailments 80% of males consulted versus 63% of the females. As noted under the vaccination section physical accessibility does not seem to be an issue.

75% of the patients consided themselves cued while. 19% did not. 6% were still under treatment at the time of the interview.

d) Expenses

Patients were asked how much they spent for the consultation fee (if any), how much for the medicines, how much for transportation. Opportunity costs (loss of wages or else) were not included.

GK Survey Rcporl

Looking at the expenses by institutions:

The only pdent who went to GK was heated k c . Data was collected for 2 o tha NGOs Radda Barnea and UFHP. The costs for averaged typs of consultation (Cold and diarrhea) are the following:

e) Practices in use of diurbu -

In takas Mean Median Maximum Minimum

In case of a diwhcaldysentery episode 46% receive antibiotics. 30% of the paticats received n o d food, ORS and antibiotics. Oral Rehydration Saline pack& are more popular (82%) than lobon-gur saline (24%) as a means of home bratment of diarrhea 23% of all mothas reported ignoring how to preparc the Lobon-gur sohUbn 79% of the people who claimed they hew about the correct way to prep~re the lobon-gur Saline were correct Overall 208 households (39%) out of the 535 surveyed did not know how to prepve adequately the lobon-gur solution. Given the ubiquitous presence of ORS packas it might not have consequences.

f) Antenatal care dnrimg the last prqpmey

CK 0 0 0 0

Among dl women interviewed 41% had no antenatal care visit during their last pregnancy, 10% had at least one; 14% two, 20Yo three. I5 % only had the fwr recommended visits. A breakdown by year of delivay o v a the past 5 years shows a reduction of the percentage of zero visit behveen 19% and 2001 finm 78% to 3 1 %. For 3-4 visits there was a positive trend until 2000 but it does not seem to have kco sustained. Among those who had at least one visit 10% never had their blood prrsurr chaked during the ANC session.

g) G.K. in the b-roviders scene Out of 535 slums houdolds situated in the immediate vicinity of the GK health clinics 33% had heard of the name "Gonoshastyo Kendro". The intaviewm used both the long and the short name. Respondents named o tha organizations that they hew. 13% of the respondents said that they had visited a GK clinic.: 36% for EPI. 37% to buy

medicines, 7% for family planning and 5% for 'fever". Out of the 70 usas 86% wen satisfied by the services. Out of 10 dissatisfied customen 3 claimed that they were not cured by the m m t , 4 that it was too expensive and 2 that "the services wen not good".

Radda Barnen 38 30 60 25

GK S w c y Report 10

UFaP 51 51 92 10

Objectives

The overall objectives of the survey were to assess the level of routine immunization and 9th NID coverage in the villages bordering the Sunderbans. Apart from immunization data, health care practices data were also collected. The specific objectives were:

a) to assess the levels of routine immunization coverage of children (12-23 months) and to find out the reasons for non-immunization and partial immunization.

b) to assess the levels of TT immunization coverage in women of child bearing age (15-49 years) regardless of their marital status and to find out the reasons for non-immunization and @a1 immunization,

c) to assess the coverage levels of OPV and TT vaccine during the 9th round of h m campaign conducted in April and May'2000 and find out the reasons for non-immunization

d) to explore health care practices and health care seeking behavior in the areas bordering the Sunderbans.

GK Survey Repon

Methodology and limitations

Vaccination coverage surveys generally follow the WHO recommended 30-chrsler survey method' which has been widely used in many developing countries to assess immunization coverage. It is relatively simple and can be used at low cost. The detailed survey methodology and its limitations are presented in Annex A. Briefly, the immunization information is collected on a randomly selected group of 210 childredwomen h m 30 clusters (7 childrenhvomen per cluster) in a given community. It gives an estimate of immunization coverage to within +/- 10 percentage points of the true population proportion with 95% statistical confidence. assuming a design effect of 2.

In this survey however the 30 clusters were not chosen randomly h m a list of the Zone 8 ward's population. Instead the t ist 14 clusters were assigned to the slums marst to the 14 clinics operated by GK and the remainden 16 to the largest slums (not already selected) nut-to-closst to the GK clinics. The change in methods was done to be as fair as possible to the GK activities sin= the people interviewed would be living very close to the centers where GK had health activities. Clusters are listed in Annex B and their locations are siown on the map. The WHO standard questionnaire was used in this survey for documenting the routine immunization dam of children and women. Separate questionnaires were used for collecting the data on the NID and health-seeking practices indicators.

In this survey 7 children between 12-23 months (born bemeen March I . 2000 and February 28th. 2001) were selected h m each cluster to ascenain their routine vaccination stam. Seven women between 1549 years of age, irrespective of their marital status were selected to ascatain their tetanus toxoid vaccination status in routine immunization. Data on health care indicators were collected h m those households where children less than 5 yean were found. The fim 7 households having 7 children 0-5- years were selected in each cluster to obtain information on the NIDs.

The IOCH survey team collected data between March 3-15. Data entry and analysis was done by IOCH using COSAS 4.3' and EPI Info programs. The Chief of Party of the IOCH F'rojecr prepared the final report.

Limitations of the 3h lus t e r survey method

Although the 30-cluster survey method is relatively simple. it has several limitations2 that can be grouped into two types:

Linked to the sampling method:

As an inherent bias in the sampling technique in 30 clusters, bigger villages with dense population are more likely to be selected as a cluster. The survey leaves out scatted small villages, usually with poor access to services. I t also docs not reflect the lack of uniformity in service availability or the behavior of particular population.

There is a wide confidenee interval (+I- 10°%). It means that if the result shows tha~ 45% of the children received a valid dose of measles vaccine before 12 months of age, hem the 'true' figure of measles immunization of children could be anywhm between (45-10) = 35% and (45+10) = 55%. This type of survey is useful when the coverage is low but is less relevant to assess higher coverage or to compare surveys - unless there is a big difference between two surveys.

To be relevant the analysis of valid data must apply to a relatively high percentage of available cards.

Linked to the implementation:

The selection of index house is key. Too often the proper method is not followed because the surveyors do not make the effort to number all the houses h m their tend location to the end of the village along the direction indicated by the bottleor by the pencil.

If a household includes an eligible child who is not at home for few hours, the surveyor often does not return later on but skips the house and substitutes another child. This is of course, an incorrect procedure that introduces a bias.

It is also important to remember that this survey coverage data gives little information about the current program as it documents the activities of a year earlier.

GK Survey Reporl

Results

A. Routine immunization coverage levels of children

Coverage levels (card plus history data of COSAS anatysis)

Table 1: Routine immunization coverage levels of the children

Table 1 shows the coverage levels of children between 12-23 months of age and tbci vaccination status at 12 months of age. The crude data figures for the 12-23 months age group indicates that 93% of the childm have access to immunization services, 80?4 of the children received three doses of OPV and DPT and that 72% a dose of measles vaccine. 72% of the children received all antigens. The figures are at the same level that the national figures which, considering the fact that the coverage levels refer to slum children is remarkable.

Name of the vaccine

BCG OPV 1

The valid coverage levels are only slightly lower. 75% of the children received three doses of OPV and DPT and 72% were vaccinated against measles. The d i f f m e betwear crude and valid for all doses received is minimal. reflecting the good quality of vaccination sessions. 6% of the children surveyed had not received any dose of vaccine and had therefore no contact with the routine EPI program. Overall 57 %of the children are hrlly immunized by valid doses by the age of 12 months, a better-than-average m l t (the national average figure is 53%). particularly for a slum area

GK Survey Report

Coverage (%) Immunized

by 12 months of age Valid data

94 93

Coverage (%) Immunization of 12-23

months age gronp

81

Crude data (A-s)

94 94

OPV2 88

Valid data

94 93 83

OPV3 80 DPTl 93

75 73 92 92

DPT2 88 83 81 DPT3 80 75 73

Measles 72 72 62 Fully immunized 72 68 5 i I

I

Zem Dose 6 -

Routine immunization coverage levels by gender I

Among 210 children surveyed therc werc 101 male children and 109 female childm. Tabk 2 shows that therc is already a slight difference in the initial level of access (DFTI) between boys and girls. However, for all valid doses by 12 months, there is a difference as only 5194 of the girls (versus 63% of the boys) arc protected. The dropout and the rate of invalid doses are higher among girls.

Table 2: Routine immunization coverage levels by gender of the child r

Program access percent of children surveyed who received DFT 1st dose, (crude data - by card or history). Access to immunization is good as 93% of the children raeived a 1st dose of DFT. But there is already a 4-percentage point gap between boys and girls in access.

C r I,

Program continoity (dropout rate)

Crude data for antigens raeived by 12-23 months of age isused for calculating the dropout rate. In this survey, the DFTI to DF'T3 dropout late is 14% and DFTI to measla dropout rate 22 % (Chart 1).

Chart-1: D r o p n t rate for childhood immunization

V -- -

DPTl to DPT3 DPTI to Measles

Program quality

Adherence to immunization schedule-invalid doses

Adherence to immunization schedule is generally considered to be the major indicator of program quality. Invalid doses' of immunization are v e v lo\\-. a credit to the quality of the senice. at least for those who had retained their cards.

Table 3: Invalid doses of immunization provided to the children

-

1 Measles I

0

I Antigens

BCG vaccination

Percentage

93% of the children suneyed received BCG vaccine based on card plus history data. S S O o of the children --ere found with a BCG scar, but in 9% of the cases BCG vaccination did not produce a visible scar. It is usually expected that the failure to produce BCG scar should not be niore than 5%.

1 DPTl I 1 I

GK Survey Repart

hiissed opportunities for immunization

Overall missed opportunities are higher than espected for DPT OP\'l. even ifcorrected later.

Table 4: Ziissed opportunities by antigens

i S a m e of the vaccine Uncorrected Corrected Total rent l u m b e r Percent

7 - 4 - 1" o I --- 1 DPTl 5 - 10 i -" o 7

c DTPZ 0 0 1 - 1 -0 - 0

g DPT3 - 1 I 3 I 1'0 - . 7 in .

Availabiliq of documentation of immunization

Child immunizarion cards \\ere available i l l 14"0 of :he cases and \\ere lost I!\ ai:a;her i3"i ~ F ! h s cases.

Table 5: EPI card availabilip and retention

- 1 EPI card rerention I 90 4 -

Because one might expect that card's retention \vould decrease \\.it11 the age of h e child Table 6 \\-as prepared. The percentage of card available does nor shou \ ariations correlared \\.ith increasing age.

Table 6: Age distribution by card and history

Source of immunization:

Two types of analysis of the source of vaccination of DPTl were undertaka one only horn the children who had a card and the other h m the cards and history collected (reliably) hom the mothers of the children. From the cards available at the time of the survey the following distribution was obtained: Radda Bamen 71%, other NGOs 16%. GOB 7%. GK 2% any hospital 3% and home 1%. From the cards and history the distribution varies a bit: Radda Bamen 57% other NGOs 24%. GOB 10°/o, GK 3%. home 2% and hospital and private clinics 3 and I% respectively.

Initial access to immunization semces is good in the slums of Mirpur. O v e d erode coverage is close to national average. Valid coverage m d valid coverage by 12 months are above national figures. However there is rwm for improvement m d the dropollt rate should be reduced.

What is the context in which the apparently small contribution of GK to the immunization of the children in Mirpur should be understood? Fint the survey. by sampling children aged 12-23 months in March 2002, analyze the activities that took place between March 2000 and March 2001. However GK arrived in the area in May 2000 and its vaccination activities staned in September 2000. Since GK is competing with other NGOs that have been working for many years in the same area it is not surprising that the first months of GK vaccination activities had a poor yield. Geographical access is not a significant factor in the low usage rate as 400% of the people surveyed were found to live 5 minutes or less on foot horn a GK clinic and 86% at 10 minutes or less. IOCH staff assessed the distances by waking themselves.

Cbart-2: Sources ofDlT1 by Card

Cbart 3: Sourca of Dm1 by card and History

Hospital 3%

- Private Clinic

1 %

OthersNGO 24%

GK Survey Report

Table 6: DbhoCe between the child's home and the CK vaccination sites by type of transports

Reasons for non-immunization and partial Lminunkation of the children

The main for non-immunization were the lack of knowledge of h e parenWauUakerS about the importance of immunization and h e fear of adverse mactions. 'The main reasons for partial immunization were the ignorance that a subsequent dose was n d e d and to a lesser extend: mother busy. child away b m home and child sickness.

Chart 4: Respondents' knowledge about required visits to immunization -ten

W)

4 5 ~ 37 40 ~

3 5 ~

3 tima 4 t i m a 5 U m a 6 bima Don't b o w

GK Survey Repon

National Immuuization Days

Table 12: Covenge of the ln round of loa NID Campaign

Table 13: Covenge of Vitamin "A" by Age group

92% of the 0-5 year children received OPV on the day of the lo* NIDs and an additiordr)C during the subsequent child-to-child days. 80°h only of the eligible children received V i h A (against an officially reported rate of 95%). Further analysis reveals tha~ only one child undrr12 months was given Vit A by mistake. The poor coverage might be explained by i n s u m supply (unlikely as not reported to supervisors) or by poor management of the fixed IOCH has no reason to question the reliability of its experienced surveyors

Vit "A"( %) 80 -

Site At fixed site During house visit

Table 14: Reasons for non-immunization of OPV during loe NID campaign (N=17)

OPV (%) 92 3

GK Survey Report 21

Reasons Did not know about NID Too busy Waited for house visit Child away from home Others

la Round (74) 47 29 6 12 6

Cllarr 8: Source of i~~fol-mntion nhour the 1O"'SID cnn~prign

IT Immunizations

Chart 5: Routine immunization coverage levels for IT of women (15-49 years)

Table 10: Age distribution olwornen who never received IT vaccine

17% of the women surveyed had never received a dose of TT. Table I0 shows that there was no age-related cluster effect for the group 20-35 but that the younger and older age-group had received less attention.

GK Survey Report

Chart 6: IT Immunization dropout among women 15-49 years

Chart 7: Providers of IT immnnization

GK S w c y Report

Table 11: Rercons for non-immnnbation and partial immnniutiw for TT of the women I

Partidly immuniution

Reasons

Next dose is not yet due Don't feel need for immunization Health worker did not specify the next dose In our times lT immunization was not in practice As per HW advice 2/3 lT is enough during the pregnancy Unaware of need of next dose Vaccinator absent

Antenatal check np meived by year

Non- immnniution

Fear of injection

Table shows the distribution of ANC visits during the last pregnancy of 506 slum resident women. 41% of them had no visit, 85% less than 4 and only 15% the required numba.

(%) (N=34) - 53 - I5

A breakdown by year of delivery over tbe past 5 years shows a reduction of the percentage of m visit between 1996 and 2001 born 78% to 31%. For 3-4 visits there was a positive trend until 2000 but it does not seem to have been sustained.

(%) (N=98) 8 - I4

22 50 1

Busv with household works I 3 I - 7 24

Among those who had at least one ANC visit 10% never had their blood p- checked during the ANC session.

2

Antenatal check-up received dnring the last pregnancy

GK Survey Repor(

Patterns of ANC visits by year of delivery

Looking at trends over the years the s w e y found that the proportion of pregnant women nithout ANC decreased gradually h m 78% before 1996, 45% in 1998 to 32% in 2001. The proporlion of women getting one and two visits increased in the same period from 2 and 4% before 1996 to 13 and 12% respectively.

Blood pressure checking done during the last pregnancy (N=301)

GK Survey Report

Number of times Not Checked One time Two tlmes Three times Four times F~ve tlmes SIX tlrnes Seven times Eight tlrnes

Number 29 53 66 82 32 21 7 6 2

Percent 10 18 -- 77

- 7- I

10 - - 7

2 0 6

Nlne times 3 I I

Health seeking behavior Access to health care and health-seeking behavior

a) Morbidity In the 2 weeks preceding the survey (late February) 137 people were sick. 64% sufFaed h m common cold with fever. 23% of diarrhealdysentery and 13% h r n other causes. Among those suffering h m coldfever 22% were infants (Yo of the total population) and another 43% between 1-5 years of age (% of the total population). For diarrheai'dysentery the proportion was 9% and 50% respectively.

Illness type

group category.

Coldfever DiarrheaIDysentery Others

Sex !

Male 1 Female

<1 year

Age and gender distribution of pat~ents: both genders were equally suffering in each age-

b) Physical access to health care . Percentage of slum residents living within minutes of the nearest curative health facilities

1-Syears ( >Syears

# 19 3 1

Private Clinic 1 ' 0.1 Shishu Hospital 3 3

Multiple responses were c o n s i d d

Total

Yo 22 9 6

<1 year 1-5 year >5 year Total

GK Survey Report 27

# 37 16 7

# I % 31 / 35 13 ] 41 10 1 55

7'0 43 50 39

# I % 23 100 I

# 11 33 28 72

# 12

# % 87 100 32 100 18 100

% 48 55 52 53

Yo 52

27 45 ; 60 100 ' 26 45 i 54 100 !

65 j 47 i 137 ? ; 100 I

Among the private health care providers been called upon 36% less than a quarter mile h m people, 61% less than half-mile and 88% less than a mile and a half. The mean distance was .83 mile. 33% of the pharmacists live within a quarter of a mile and all within a mile and a half. The mean distance was .7 1 mile. 25% of the people who consulted a GOB health facility live within a quarter mile of it and 75% within a mile.

c) Bullh Care seeking behavior AU families wen asked when do they x~nmally go for t r e a ~ ~ ~ e n t if they s&k treatment Pharmacists came tirst (57%). then private doctors (24%). Radda Bamcn (I???). various NGOs betweem 2 and 4% and UFHP aad GK last ((.FA).

Type Pharmacy Private Doctor Radda Bamen

1 GOB 10 2

~ -~ ~-

Others NGO Homeopath

1 GK 4 0.7 However when the families which had a member sick in the last 2 weeks were asked where they went, the relative importance of the above categories changed somehow: pharmacists (51%), private doctors (14%). homeopaths (7%)). MBBs and Mary Stopes (6%) while Rad& Barnen and GOB were used in 3% of the cases. GK ruuains at the same level (I %). Who consults and for what?

Nnmber 307 126 41

GK Survey Report 28

Perrat 57 24 8

20 13

4 2

Marv stoves 10 pp

2

It should be mentioned that not evayoae wwlts in case of illness: only 63% in case of common wld/fcva and dianhddysentay. There was no gender d i f f a a ~ e . For other ailments 80% of males consulted v e m 63% of the fanales. As noted under the vaccination section. physical accessibility docs not seem to be an issue.

Type of health are provider consnltcd firat by gender of the patient

Hosp~tal - 2 100 2 2 Others NGO - 2 100 2 2 Kabw 2 100 - - 2 1

ICDDRB - I 100 1 1 Total 46 52 42 48 88 100

Half of the patients went to consult pharmacists and 14% a private doctor, with no gender preference. Homeopaths (7%) and MBBS (6%) are p r e f d by men. For the other pmvidm the numbers are too small to be interpreted.

75% of the patients consided themselves cured while 19% did not. 6% were still under m e n 1 at the time of the interview.

d) Expenses

Patients were asked how much they spent for the comltation fee (if any), how much for the medicines, how much for transpor(ation. Opportunity costs (loss of wages or else) were not included. Looking at the expenses by institutions:

The only patient who went to GK was beated k. Data was collected for 2 other NGOs Radda Bamm and UFHP. The costs for averaged types of consultation (cold and diarrhea) are the following:

GK Survey Rcpotl 29

I - -

UFHP 5 1 5 1

In takas Mean Median Maximum 0 60 I 92

GK 0 0

Radda Barnen 38 30

Minimum 0 25 10

e) Practices in case of diarrhea

In case of a diarrhealdysentery episode 46% receive antibiotics. 30°/00f the patients received normal food, ORS and antibiotics.

Oral Rehydration Saline packets are more popular (82%) than lobon-gur saline (24%) as a means of home treatment of diarrhea.

23% of all mothers reported ignoring how to prepare the Lobon-gur solution.

79% of the people who claimed they knew about the correct way to prepare the lobon-gur Saline were correct.

Overall 208 households (39%) out of the 535 surveyed did not know how to prepare adequately the lobon-gur solution. Given the ubiquitous presence of ORS packets it might not have consequences.

f) Antenatal care during the last pregnancy

Among all women interviewed 41% had no antenatal care \.isit during their last pregnancy; 10% had at least one; 14% two, 20% three. 15 ?.o only had the four recommended visits. A breakdown by year of delivery over the past 5 years shows a reduction of the percentage of zero visit bet\veen 1996 and 2001 from 7S0h to 7 1''; For 3-4 visits there was a positive trend until 2000 but it does not seem to have been sustained.

Among those who had at least one visit 10% never had their blood pressure checked during the ANC session.

g) G.K. in the health-providers scene

Out of 535 slums households situated in the immediate vicinity of the GK health clinics 33% had heard of the name "Gonoshastyo Kendro". The interviewers used both the long and the short name. Respondents named other organizations that they knew.

13% of the respondents said that they had visited a GK clinic: 36% for EPI, 3796 to buy medicines, 7% for family planning and 5% for "fever".

Out of the 70 users 86% were satisfied by the senices

Out of 9 dissatisfied customers 3 claimed that they were not cured by the treatment. 4 that it was too expensive and 2 that "he senices were not good".

GK Survey Report

Conclusions

The slums infants of Mirpur have access to immunization S ~ M C B and their vaccination coverage is above the national figures. There are gender differences that deserve immediate attention. Informing better the mothers when to come back and why no protection is complete until and unless 8 doses have been received should reduce dropout. The sunrey did not evaluate the quality of the cold chain, the vaccine potency and the quality of the vaccination sessions.

NID coverage was good but the reasons for the low Vit. A coverage should be explored and corrected during the coming SNIDs.

The 5 doses IT policy needs to be implemented more v~gorously. particularly \v~th young women.

GK's contribution to EPI, IT and curative care appeared minimal. The possible explanations have been discussed in another separate report. In a context of a plethora of health senices providers (many of them settled there a decade ago) the specificity of the role of GK needs to be revisited.

GK Survey Repon

Reference and Resource materials

1. WHO EPI Mid Level Managers module: Evaluate Vaccination Coverage (WHOIEPVMLMI~~.~ 1)

2. Anthony G Turner, Robert J Magnani and Muhammad Shuaib, "A not quick as quick but much cleaner alternative to the Expanded Programme on immunization (EPI) cluster survey design", International Journal of Epidemiology, 19%, volume 25, Issue No. I, pages 198- 203.

3. COSAS 4.3 version manual, WHO. November 1991.

4. Training manual on EPI for the field workers of Ministry of Health and Family Plnrmin& 4* edition, 1997.

5. Expanded Program on Immunization, Ministry of Health and Family Welfarei 1997, 1998, 1999 National Coverage Evaluation Survey Repo* Dhaka

6. Needs assessment study of field workers involved in the Expanded Program oo Immunization, Executive Repo* November 1991, Pages 2-8. 1 1.

7. Progotir Pathey, October 1998, UNICEF, Dhaka

8. Stanley 0. Foster, 1996, Information for action: Using data to improve EPI impact. BASICS. Dbaka

9. Therese Blanchef Perceptions of childhood diseases and attitudes towards immuoiLation among slum dwellers, Dhaka, June 1989. AID Conbact No. DPE-5927-C-5069840.

GK Survey Report

I Annex A 1

The following arc cxmcts horn Anthony G T-, Robert J hhgnsni and Mnhamuud S u m ' s urick anifid 'A nor quick u qauk bw much h a .I*nrmiu to the Erpuld R q m m m r or Iuuh.air (WI) dmer survey dmgn" publuhed in the lnternarional J o d of Epidemiolo~ in 1996. w l m e 25. lznn No. I . pages 198- 203.

Tbe scdndard EPI C h s t a Survey h i e n

The sample design for t& EPI Cluster Survey is a two mge design involving Ih xkction of 30 primuy sampling units or 'chrrtcn' (omally village or other a m units), from which 210 childmn witb a Prga age nnge (usually 12- 23 month) arc chOSe4 xven children pa cluster. Tbe sample size of 210 childmu @n dmuio or nnnm) is mandated by the kin to aimate h e level of Lmmmintion covmge to within +I- I0 pxmnnge points of I& m e population proportion witb 95% mtittical comidmce. assuming a des~gn effect ( i t . d f l of 2.0. Based upoa prior experience witb immmization covmge m e y s @rimuily in chc US). 30 clustcn uc gcnnlly tbougbt to be neccssaty to yield arfSciently reliable estimate.'

"In t& scdndard &sign, chrctm arc chOSen from a list of prima^^ sampling units (ie. vihga. u h n c p census ermmcntim nrrar CDE.) thrOugb symrmtic Rodom sampling witb pdubilny proparion+l to cstinnbd size @p). Tbe latat &imam of cluster pDpllrtion size& which arc d to be m o d m L& nlrmber of children in the target age group in each cluster, uc typ idy used as mevurrr of size. Tbe 30 chmm so cbovo ue tben visited by survey field staff wbo carry out the second stage of sample xlcdon d ccmduc~ t& bapcbold interviews. '

T h e original EPI design d c d for sample childmu to be chmn nndody from a list of rll eligiik chiklrm in a c h sample chum. However, because Ih creation of lim of bouxbolds and childmu tmdr to bc b amming . costly, d unfeasible in some setting& thir proccdurr is only infrsquenrly used in d pwticc. Lrma4 on of seven1 simplified second stage sampling proudum is commonly used. In ooe variant. c b t l h are sekcted by T i choosing a random dirstion from a central location in a village or community (e.g. by spinning a bonk). The number of hweboldr in b t diration to dx edge of t& community is tbm counvd d ooc barvbDld is nndomly chovn to be t& Fmt sample bouxbold Suhxquent bouxholds chaSm by visiting t& narcst ocigbbfng houvholdr lmtil information hao ban g a t h d on seven childm~. Ln a yet simpler variant. a dimaim from a central starting point is nndomly cbovn as hi above d bouxholdr arc COnbcted as the i m a v k w u mows in tbe chavn direction until tbc mired information hao been gathered for seven childm'

The d stage sampling wthodr hi above ue 'quoa sampling proccdurrs' d umr of t& p u b h ~ h t & u s e o f t h i r . p p m s c b h v e b c c n n o t e d o v a c b c y . '

Tirst, quota sampling doa not aumr t h t every eligiik memba oft& arga poplLtian hm a b m ma-= chmaof~grcLcadHcnx,~rhDdudEPIkign,mitisdlyrpplKdn~a~pob.b~liryrrmpk daign . . . . . . . . . . . . . . . . . . :

'A ssond pmbkm concern -ling n i g h . ..... ......... Howma, dnc mclnms of size in sampling hmcs arc of tcn iDaccun l~mKtoocoau-dchnga inpop lL t imr iwt&ce~rus~oL~rpp l iu t iooof t& scdndard EPIChrmrSurvcymcmoddoa~~~dmaoclfrrigb~ump*.Tbcarrvcy&tawot bc weighed in orda to yield l m b i atinnt~~ . ...... ... .. Howma, siaa xkcboo probabilities m lloc b s m in mon EPI Cluster Survey appliatioly sampling weights a n lloc bc calculated.'

'Thirdly, a computer sunulation snrdy d c m o m t a rht cbc EPI Clvaa Survey based upon quota rrmpllng at cbc . - -ad stage able selection is corrridmbly more pmoc to sampling bias th. conv&tioA chner sampling. puticululy slbm. ' ed c h i l h arc 'pocketed' within chmcm '

'FinaUy. cberc is chc irsue of bow second stage sample selection should proceed in surveys w~tb multipk me~surnmat objectives.-

GK Survey Rcpon

List of Selected Clusters for the Survey

08 05 11 Bauniabad Slum. Block-B

08 05 12 Tallola slum

08

08 - 08

08 05 13 Bauniabadh. Blockc

08 05 14 Bihari Camp (Beside Bauniabadh. Blockc)

08 05 15 Bauniabadh. Block-€

08 05 16 Bauniabadh. Block-D

08 05 17 Babul Miar Baslee

08 05 18 Millat camp (Anto zila Truck samity's baside

08 07 19 Shiabari slum. 7 no. Road

Zone

08

08

08

08

08 07 20 Hajee Road Bastee. Shialbari

08 02 2 1 2 no. BaburmaIh slum

08 02 22 Murapam Camp

08 02 23 Baluarmalh 6 no. slum

08 02 24 Baburmath 'Dha' Block Bastee

08 02 25 Basluham ceramic Bastee

08 02 25 Ceramic Bastee

08 02 26 Gani Miar Baslee (12 6. Road-2)

08 02 27 Jamal Miar Bastee

08 02 28 Bloek-B. Road -4

08 07 29 Duaripam (Asha mirpur)

06 42 30 Bijli mahalla

Ward 03

03

03

03

Cluster No. 01

02

03

04

08 03 08 Mathor Patt~ (Avenue-5) . 08 05 09 Bauniabad. Block-A

08 05 10 Kalabagan slum

04

GK Survey Report 34

Cluster Name

DarogalChoukidar-er Basti. W - D

Avenue-5's Slum (Abbasuddin School's behind)

Mirpur 101A

Musltm camp

05 Ba~shtek~ slum (Beside power house)

04 06 Ba~shlek~ Natun Bazar Slum I

03 07 1 Mohangar BNP office area

Annex C

List of Never Vaccinated Children Identified by Clusters

GK Survey Repon

Never vaccinated I children I

3

08

08

08

Zone

08

Ward

04 No. 05

08 07 20 Hajee Road Bastee, Shialbari 2 I

08 02 26 Ceramic Bastee I I

08 1 02 27 Gani Miar Bastee (12 6, Road-2) I 1

04

03

05

Cluster Name

Baishteki slum (Beside power house)

06

08

13

Baishteki Natun Bazar Slum

Mathor Patti (Avenue-5)

I 3 I

1 I

Bauniabadh. Block-c 1 I I I

Acknowledgements

Survey coordinator: Dr. Piem Claquin. Chief of Party. IOCWMSH Md. Mafizur Rahman. M o n i t D ~ g and Evaluation Specialist+ IOCWMSH

Survey management: Mr. Jagadindra Majumder. Field Survey Manager, IOCWMSH

Datn analysis: Ms Shahida Akhta Ripa, PEF Monitoring, IOCWMSH

Report preparation: Dr. Piare Claquin, Chief of Party. IOCWMSH

Report review: Dr. Pierre Claquin, Chief of Party, tOCWMSH

Digital map prepared by: Mr. Din Mohammed, Monitoring and Evaluation Assistant, IOCWMSH

Cover photo: Ms Moumina Dorgabekova, Image Jinn

Survey term members: Md. Saiful Islam, Field Investigator, IOCWMSH Md. Abdul Hamid, Field Investigator, IOCWMSH Ms. Krishna Rani Shil, Field Investigator, IOCWMSH Ms. Mahmu& Parvin, Field Investigator. IOCWMSH Ms. Aung Ma Ching Marma, Field Investigator, IOCHMSH Ms. Niva Rani Toju. Field Investigator. IOCWMSH