Discussion
Our study findings show that integration of immunisation into outpatient therapeutic programme centres and nutrition programmes improved immunisation coverage and reduced drop out rates. Children were more likely to be immunised with the first dose of pentavalent vaccine after immunisation service integration into the nutrition programmes of the PHCCs compared with integration into paediatric outpatient departments. However, no association was observed for the second and third doses of the pentavalent vaccine. Additionally, this study observed low immunisation coverage among children above 1 year compared with children below 1 year.
Similar inferences have been highlighted in prior studies on the benefits of integrating the EPI with comprehensive health service delivery and recommending broader adoption in South Sudan.25 26 34 35 In the Rumbek Centre county, our inferences on improved immunisation coverage through integration into nutrition programmes are supported by findings by Oladeji et al in a similar study25 conducted in the Liech state of South Sudan which also found increased childhood immunisation coverage and reduced drop-out rates. The study also highlighted a higher adherence to vaccination among children vaccinated at outpatient therapeutic programme centres in comparison to PHCCs. Similar supportive evidence has been generated by related studies with a positive impact on nutrition outcomes36 and that nutrition counselling and education improved coverage of the third dose of the diphtheria, pertussis and tetanus (DPT3) vaccination by 68%.37 Since nutritionists assessed the immunisation status of the children before enrolling them in the nutrition programme, this ensured that missed opportunities for immunisation were assessed and counselled. Also, integration has been successful the other way around as well when other interventions such as vitamin A supplementation to immunisation campaigns have improved immunisation coverage.38
In the Rumbek East county, the improvement in immunisation uptake can be attributed to regular monitoring, motivation and health education in the paediatric outpatient departments of PHCCs. Also, mothers/caregivers would like to vaccinate their children in an outpatient clinic where they can access free treatment, and most mothers who deliver in the clinic receive adequate antenatal care which could increase immunisation uptake as well. These findings are corroborated by a systematic review on childhood immunisation interventions in low-income and middle-income countries, which found that facility-based health education plus redesigned vaccination reminder cards in outpatient departments improved coverage of DTP3 vaccination by 50%.37 On the other hand, we believe that the impact of the intervention in Rumbek East county was thwarted by a communal conflict between the two major communities—Pacong and Aduel communities from August to September 2019. However, some of the children who missed their immunisation schedule as a result of reduced access and uptake of immunisation and nutrition services due to displacement or fear of mobility were traced and vaccinated using a supplementary immunisation strategy in the month that followed the crisis. This can be seen in the spike of pentavalent first dose uptake of Rumbek East county in October 2019 (see figure 1).
We observed reduction in immunisation drop-out rates after integration in both nutritional programmes and paediatric outpatient departments of PHCCs. Similar reductions in drop-out rates have been recorded among children attending a paediatric outpatient clinic at Juba Teaching Hospital in 201739 and in a health facility-based study conducted in South Sudan.40 The missed opportunities for immunisation were relatively similar in both Rumbek Centre and Rumbek East counties after immunisation service integration.
The distance to access immunisation services is a good predictor of vaccination coverage in low-income and middle-income countries. Low vaccination coverage has been reported among caregivers living farther away from the health facilities if no growth monitoring programmes and incentives were provided. This finding is consistent with a study in Zambia which showed that immunisation uptake was lower among caregivers living further away from the health facility before a growth monitoring programme was introduced into the immunisation services.41 The barrier posed by longer travel distances to access immunisation especially for the second and third doses of the pentavalent vaccine could be partially addressed through incentives to attend the PHCCs in both Rumbek East and Rumbek Centre counties.
Immunisation uptake of the first, second and third doses of the pentavalent vaccine was higher among under 1-year-old children in comparison to children aged above year in both the Rumbek East and Rumbek Centre counties. In West Cameroon, a study showed similar findings where immunisation coverage of the pentavalent vaccine decreased as the children’s ages increased.42 Although we did not assess the factors associated with low coverage among children aged above 1 year, other studies have reported limited parental knowledge on child health management, fragile vaccination health services, geographical limitations, economic struggle, mother’s level of education and cultural accessibility as the major reasons for the low uptake.42 43 We hypothesise that the high child care burden of the mothers due to high fertility rates coupled with other household chores, poor community sensitisation and internal displacement contributed in part to the low immunisation rates among older children.
While childhood immunisation coverage among under 5-year-old children in low-income and middle-income countries is below the global average, the coverage is relatively even lower in South Sudan especially in the conflict affected areas.25 The EPI was initiated in 1974 by the WHO and United Nations International Children’s Emergency Fund44 through a vertical approach which later shifted to an integration approach by integrating immunisation services with other health services within the Integrated Management of Childhood Illness context.45 The reasons for WHO’s recommendation for horizontal integration of childhood immunisation with other health programmes are improved efficiency and cost savings.46 This stems from a decrease in competition for resources and duplication of the health systems in comparison to vertical programmes. Immunisation service integration also has challenges, such as overburdened healthcare staff, unequal resource allocation, difficult funding mechanism, donor policies and logistical difficulties.23 Therefore, the benefits inferred in this study for immunisation service integration with nutrition programmes and paediatric outpatient departments in PHCCs will need to be assessed against the risks imposed by operational logistics and compatibility differences between health programmes for successful integration.27
The nutrition services in our study were planned to facilitate codelivery and a shared-information approach was used to ensure that all the services were provided at the nutrition centre. Children’s nutrition status and growth monitoring are important to mothers and caregivers and hence the drive to attend nutrition services delivery programmes.47 Consequently, nutrition services such as growth monitoring, nutrition counselling and education were placed as core services while immunisation services were also conducted. This highlights the benefits of integrating immunisation services into nutrition programmes to improve the childhood immunisation coverage, as inferred by our study through increased uptake of the pentavalent vaccine. Sustaining community-based activities is a major challenge in low-income and middle-income countries.41 47 In our study, the nutrition programmes at the PHCCs of Rumbek Centre county provided nutritional incentives for the community. Provision of incentives especially in community programmes has been shown to be effective in motivating communities, improving effectiveness and impact of the programmes.48
In the paediatric outpatient departments, recipient-oriented interventions such as recalls and reminders, health education, teaching recipients’ skills and provider-oriented interventions such as health services audits and feedback mechanism, chart based or calendar reminders were also provided. While we infer in our study the increased uptake of the pentavalent vaccine, this also highlights the benefits of integrating immunisation services into paediatric outpatient departments to improve childhood immunisation coverage. Immunisation service integration into both nutrition programmes and paediatric outpatient departments of PHCCs have effectively reduced missed opportunities for vaccination.
Under normal operations of the vertical immunisation programme in South Sudan, after visiting the nutrition or outpatient departments in the PHCCs, mothers were asked to visit the immunisation unit which is located 30 m or longer from their current service delivery point. However, most mothers who were referred to the immunisation unit refrain from immunising their children during the same visit to the PHCCs due to the following barriers. Mothers report (1) being tired after waiting for long hours in the nutrition or outpatient departments, (2) vaccinators not being present at the time they go for vaccinations, (3) being asked to queue again after spending long hours in other nutrition or outpatient departments, (4) urgent need to return home to their domestic activities and (5) getting late to go home. As highlighted in this study, by integrating the immunisation services to the nutrition and paediatric outpatient departments of the PHCCs in Rumbek East and Rumbek Centre counties of South Sudan, mothers did not have to queue again since vaccinators were also present at the point of service delivery in the nutrition and paediatric outpatient departments.
As future directions, cost-effectiveness studies are needed to facilitate decision making and prioritisation of immunisation service integration into nutrition programmes and paediatric outpatient departments while considering the contextual characteristics of workers' training, stakeholders support, vaccine supply chain constraints and community demand for vaccination. With South Sudan emerging from protracted civil wars, we infer a favourable impact of immunisation service integration into nutrition programmes and paediatric outpatient departments in this study. This highlights a positive way forward to optimise and scale-up the integration of the EPI with other health services in the PHCCs to improve childhood immunisation coverage in South Sudan.
Our study has limitations, including the study duration being relatively short in comparison to other studies done on immunisation service integration.25 We acknowledge that a time lagged study could have improved the robustness of the study results. We also acknowledge that considering other predisposing factors such as age and sex of the child, mothers’ sociodemographics, lifestyle and knowledge about immunisation41 would be informative and could influence immunisation uptake. Further, the impact of immunisation service integration could have been influenced by the close monitoring of the immunisation service delivery by both the immunisation managers and nutrition workers.
