performance assessment of health workers training in routine immunization in...
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Study Report December, 2009
Performance Assessment of
Health Workers Training in Routine
Immunization in India (WHO and NIHFW collaborative study)
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Study Report
December-2009
Performance Assessment of Health Workers Training in
Routine Immunization in India
(WHO and NIHFW collaborative study)
Principal Investigators
• Dr. Deoki Nandan, Director, NIHFW
• Dr. Hamid Jafari, Project Manager, WHO-NPSP
Chief Investigators
• Dr. Utsuk Datta, Professor, Education & Training, NIHFW
• Dr. Sunil Bahl, Dy. Project Manager, WHO-NPSP
• Dr. Renu Paruthi, Training focal Person, WHO – NPSP
Co – Investigators
• Prof. M. Bhattacharya, Professor, Dept. of CHA, NIHFW
• Dr. Sanjay Gupta, Associate Professor, Dept. of CHA, NIHFW
• Dr. Balwinder Singh, Ag. National RI team leader, WHO – NPSP
• Dr. P.K. Roy, Monitoring & Evaluation, Focal Person, WHO – NPSP
• Dr. P. Deepak, Consultant Immunization training, NIHFW
3
Table of Contents
Topics Page No.
Foreword 4
Abbreviations 5
Executive Summary
6
Introduction
11
Objectives of the Study 12
Methodology 12
Study Findings
14
Major Conclusions and Recommendations 37
Annex 1: State wise summary of observations and suggestions by the study
teams 41
Annex 2: Guidelines for Immunization Training of Health Workers 53
Annex 3: The Program schedule for Immunization Training of Health Workers 53
Annex 4: Day wise tasks for each study team for data collection 54
Annex 5: Study tools numbers 1 – 6 including the instructions to fill 56
Annex 6: List of Study Team Members 69
4
5
Abbreviations
ADS Auto Disable Syringes
AEFI Adverse Events Following Immunization
ANM Auxiliary Nurse Midwife
ANMTC Auxiliary Nurse Midwife Training Centre
ASHA Accredited Social Health Activist
AVD Alternate Vaccine Delivery
AWW Anganwadi workers
CHC Community Health Centre
DIO District Immunization Officer
GoI Government of India
HWs Health Workers
HA (M) Health Assistant (Male)
HA (F) Health Assistant (Female)
HQ Head Quarters
IPC Inter-personal Communication
LHV Lady Health Visitor
MoHFW Ministry of Health and Family Welfare
MP Madhya Pradesh
NRHM National Rural Health Mission
NIHFW National Institute of Health and Family Welfare
NPSP National Polio Surveillance Project
PATH Program for Appropriate Technology in Health
PHC Primary Health Centre
PNA Performance Needs Assessment
PRI Panchayati Raj Institution
SEARO South East Asia Regional Organization
SHG Self Help Group
UIP Universal Immunization Programme
UNICEF United Nations Children's Fund
UP Uttar Pradesh
WHO World Health Organization
6
Executive Summary
Baseline study on Performance Needs Assessment (PNA) of Health Workers was conducted in
late 2005, across 8 states and 40 districts to identify the areas for immunization training. The
results of this survey lead to the development of the Immunization Handbook for Health
Workers and the related Facilitators’ Guide, published by MoHFW in August, 2006. An initial
period of state-level training of trainers (ToTs) was followed by health worker training in
districts and by December 2008, approximately 100,000 of the total 200,000 (50%) HWs in India
were trained in the country.
The overall objective of this study was to assess the level of health workers performance in
providing immunization services following the introduction of the Immunization Handbook for
Health Workers and the Facilitator’s Guide (GoI, 2006). The study was conducted jointly by
WHO-NPSP and NIHFW. Data collection was done in two phases during June (8-13) and July (13-
20), 2009. The specific objectives of the study were as follows:
1) To assess the performance (level of knowledge and skills) of health workers after
training in immunization.
2) To seek the opinion of trainers and the trained health workers on course curriculum and
methodology followed during the training.
3) To seek the opinion of supervisors and beneficiaries about the performance and job
behavior of health workers.
4) To find out the non-training issues that would enhance on the job performance with
respect to immunization service provision.
5) To suggest interventions (if any) for improving the performance of health workers
(including modifications in future training courses)
The study covered a sample of trained health workers (ANMs, LHVs, Male health workers and
health assistants), PHC medical officers, District Immunization officers / Training Coordinators
and beneficiaries/care givers from the seven states, Bihar, Jharkhand, Madhya Pradesh, Orissa,
Rajasthan, UP and Uttarakhand. These same states had conducted the PNA study. Hence,
where appropriate comparing the results of the two surveys has been done, however, it must
be noted that because of the different sample sizes and methodologies used, comparisons are
illustrative and not statistically comparable.
Forty study teams, one for each district were identified amongst officers from NIHFW, WHO-
NPSP, WHO-SEARO, WHO-HQ, UNICEF, IMMbasics, Medical Colleges, Training Centers and State
governments. Data was collected from total of 2292 respondents including 40 District Trainers,
82 Block Medical officers, 313 health workers and 1857 beneficiaries/caregivers through
interviews, observation of health workers conducting immunization sessions and record study.
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Major conclusions drawn from the study and the recommendations are as follows:
1. Training
All the states with the exception of Jharkhand have trained more than 80% of female health
workers (ANMs) on vaccination of children and pregnant women, while the newly recruited
contractual female health workers and other categories as male health workers, health
assistants, cold chain handlers, data handlers etc are still left to be trained for their specific
tasks.
State governments need to release funds to the districts to continue the in-service training for
all health workers including HW (male), HA (male), HA (female) cold chain and data handlers
in their specific tasks at PHC and District level as well as newly recruited contractual health
workers.
Sixty-five percent of trainers deemed the course contents were adequate and rationally
developed. Suggested topics to be included in the Handbook were details on VPDs,
communication techniques and details on newer vaccines. One in four of those interviewed felt
that more field based sessions with practical demonstration of preparing due list of
beneficiaries and VHNDs should be included.
Training material needs to be updated based on recent policy changes and more emphasis is
required on improving the communication skills (in the handbook as well as in the facilitators’
guide).
Eighty percent of the districts had training centers and class rooms available, however, only half
had hostel rooms and transport facilities. Residential arrangements were made by 35% of the
districts.
There is need to establish or strengthen the logistical capacity and infrastructure of training
facilities and residential arrangements need to be made in each district for training.
The average batch size for HW training was 26, well above the norm of 15. During field visits,
only 38% of the health workers reported having the opportunity to practice injections. While all
training centers distributed Immunization Handbooks in local language, only 64% of HWs
reported viewing the Immunization film during training.
States need to enforce guidelines for a batch size of 15 and at least 3 trainers for each
training course. Hands-on opportunities must be provided to the trainees by taking the
participants in small batches to 3-4 different session sites. Greater oversight of training
sessions by state and district officials as well as partners is necessary.
Sixty percent of health workers reported that only 2 to 3 trainers were involved on both days of
training. Trainers’ skills were found to be weak in conditioning of ice-packs, use of hubcutters,
AEFI management and tracking of drop outs. Trainers from Orissa and Rajasthan performed
better as compared to the other states on all parameters.
States need to train more trainers to ensure adequate number of trainers in all the districts.
Trainers’ skills need to be evaluated and strengthened through annual refresher trainings.
One district level officer should be designated as nodal officer for coordinating the
immunization training of all health functionaries.
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2. Performance of health workers after training in Immunization
Injection administration skills of Health Workers appear to have improved since the PNA study.
85% of HWs were Injecting vaccine using the correct route per antigen; 75% were allowing dose
to self disperse instead of massaging and 67% were maintaining aseptic technique. 98% of the
health workers were found competent in using ADS and 96% in using new disposable syringe
for each reconstitution. However, only half of observed health workers cut each syringe with
hubcutters immediately after use.
Regular training and retraining of health workers in RI is required every year. There is a need
to provide hands on training to health workers to practice injection administration
techniques.
Documentation (recording and reporting) skills of health workers also improved after training
as compared to the baseline PNA study with 73% of all health workers documenting each
vaccination correctly and completely. However, reporting of VPDs and AEFIs was found to be
very poor across all the states.
HWs need to be supervised to ensure that they prepare the due lists, fill counterfoils and
update the Immunization registers regularly. HWs should be sensitized and encouraged for
reporting of VPDs and AEFIs.
Interpersonal Communication skills of health workers were found to be weak even after
training. 44% were welcoming beneficiaries; 40% were explaining potential adverse events
following immunization and 39% were discussing with beneficiaries/parents about the next
visit. Only 18% were explaining what vaccines would be given and the VPDs prevented; 13%
were screening the beneficiaries for contraindications and 15% were asking the beneficiaries to
wait for 15-30 minutes after vaccination.
Need to improve communication skills and technical knowledge of the health workers by
ensuring supportive supervision and on the job training by MO/PHC during immunization
sessions. As a constant reminder for health functionaries, key IPC messages in local language
should be displayed at the session site.
While 93% of beneficiaries/caregivers knew about the place of immunization session, only 49%
caregivers knew when to go for next due vaccine. Three-fourths of care givers were reminded
for vaccination prior to vaccination day by the social mobilizer and 70% children had received
age appropriate vaccines.
IEC and IPC in the community need to be improved. HWs need to share the due list of
beneficiaries with ASHA/AWW for tracking of drop-outs. ASHAs need to be trained for better
community mobilization especially in the resistant group.
3. Immunization Program support to HWs
Coverage / Microplanning: Eighty six percent of the sessions were being held as per the RI
microplans; however, a map of the catchment area was available in only 39% of the PHCs.
Estimation of number of beneficiaries and logistics as a part of microplan was limited (61% of
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PHCs). Though roster of HWs was available at 88% of the PHCs, the Alternate Vaccine Delivery
plan was available in only 61% of the PHCs.
Proper Microplans with maps are required so that no area is missed. Maps showing the
subcentres, distance of session sites from ILR points and alternate vaccine delivery plan need
to be displayed at each PHC.
Cold chain and logistics management: Designated and trained cold chain handlers were not
available at the PHCs. Vaccines were delivered through Alternate Vaccine Delivery System to 71
% of session sites. 73% of PHCs were correctly maintaining the stock registers; 64% were
correctly maintaining the temperature log books and only 48% were conditioning the icepacks
correctly. Stock-outs or shortage of vaccines or syringes in last 3 months were reported by 37%
of PHCs covering all the states.
Twice daily recording of temperature in the log books needs to be monitored. Urgently
designate and train the cold chain handlers in their specific tasks. Nonfunctioning cold chain
equipment needs to be repaired or replaced. Ensure regular supplies of immunization cards,
registers, tracking bags and coverage monitoring charts.
Injection safety and waste disposal: Forty nine percent HWs were cutting AD syringes
immediately after use and 35% were using red bags to keep cut AD syringes. Availability of
functional hub cutters at PHC (54%) and Session site (53%) was poor. Availability of red bags
(36%) and black bags (32%) was also poor at session site. Though disposal pits were made by
54% of PHCs, disinfection was practiced only by 30% PHCs; syringes and needles were thrown
into these pits meant for sharps only; burning and burying of the immunization waste was also
practiced. Only 68% of the trainers had good knowledge of the use of hub cutters and safe
disposal of immunization waste.
States need to establish a system of collection of segregated waste from session site to PHC
for disinfection and proper disposal; ensure regular supplies of hubcutters, bleaching solution,
red and black bags and also construction and proper utilization of waste pits for disposal of
sharps. Monitoring and supervision by medical officers needs to be ensured.
AEFIs: Only 53% of the trainers of health workers had good knowledge on the management of
AEFIs and 69% of the health workers knew proper treatment of minor AEFIs. However, only
40% of health workers explained potential AEFIs to care givers. Only 7% of the PHCs had
reported AEFIs in the MPRs of last three months preceding the study.
Training surrounding all aspects of AEFI needs to be strengthened to ensure that medical
officers regularly sensitize the health workers on reporting and management of AEFIs and
that HWs explain potential AEFIs and their management consistently to each beneficiary /
caregiver.
Tracking and mobilization of beneficiaries: During observed sessions, only 39% of health
workers discussed with beneficiaries /parents the date of the next visit. Approximately 30% of
beneficiaries did not receive age-appropriate vaccinations. Only 4% PHCs displayed coverage
monitoring charts and only 50% of trainers had adequate knowledge about tracking of
dropouts.
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Preparing due lists, updating counterfoils and using tracking bags should be standardized for
tracking beneficiaries. HWs need to update immunization register by including information
from the records of AWW/ASHA as well as new born tracking booklets of SIA. Coverage
monitoring charts should be displayed in every PHC and sub center and this should be ensured
through supportive supervision and on the job training by MO/PHC during immunization
sessions.
Monitoring and Supervision: Though medical officers of the PHC reported monitoring on an
average 4 session sites per month and other supervisors monitored around 7 session sites per
month during last 3 months, no records to support the supervisory visits were available in 45%
of the PHCs. Fifty six percent of health workers reported that MO had visited their session sites
in the last 3 months while 63% reported the visit of other supervisors.
Provide mobility support to medical officers for the field visit and supervision. Train all
supervisors on monitoring and supervision of all the health functionaries involved in
immunization services. The monitoring by BLOCK TEAM and by DISTRICT TEAM should be
made mandatory; this needs specific guidelines and tools to be prepared and shared with all
states and districts.
Way Forward:
• Update training materials at national level for training the health workers, cold chain and
data handlers in the states.
• Use innovative training methodologies e.g. developing web based training packages for e-
learning, videos etc.
• States need to provide refresher training to the trainers as well as all health functionaries
every year and orientation/induction training for the new staff. Annual State PIPs under
NRHM need to include all the immunization training related activities.
• Regular monitoring to understand weaknesses and tailored supportive supervision of all
health functionaries is required to reinforce training and improve quality of services and
ultimately immunization coverage rates.
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1. Introduction Immunization Training for Health Workers (HWs) was identified as a key recommendation by
both the Universal Immunization Programme (UIP) Review (2004) and the Ministry of Health
and Family Welfare’s (MoHFW) Multi Year Plan for immunization (2005-2010). Following this,
Government of India (GoI) formed a National Core Committee for Immunization training in
2005. Committee members, including representatives from MoHFW, NIHFW, WHO, UNICEF,
PATH, IMMbasics and CARE, reviewed existing immunization training materials and conducted a
Performance Needs Assessment (PNA) of Health Workers, across 8 states and 40 districts, in
late 2005. The following areas were identified for immunization training:
• Micro-planning
• Vaccine administration techniques
• Cold Chain maintenance
• Recording and reporting
• Use of AD syringes
• Safe disposal of used syringes and needles
• Management of AEFIs
• IPC and Counseling etc.
All these areas were included in the Immunization Handbook for Health Workers and the
related Facilitators’ Guide which were developed after extensive inputs from stakeholders, field
testing and a national consultative workshop, and published by MoHFW in August, 2006.
Translation and printing in local languages was done by state governments with help from
partners.
States prepared their training plans and calendars and MoHFW provided funds to states (under
NRHM) for the training. For the HWs’ training, the cascade model of training was adopted, with
members from the National Core Committee conducting Training of Trainers (ToTs) courses at
the state level, followed by the two-day actual district-level training of front line HWs. Emphasis
was on conducting participatory training, with extensive use of hands-on practice and field
visits.
ToTs were held mainly during 2007, training around 4600 trainers in 33 states. Majority of the
states started Health workers training by the end of 2007. By December, 2008, around 100,000
of the total 200,000 (50%) HWs were trained in the country. It was considered important to
understand whether the training of health workers was able to close the gaps identified by PNA
and, how well the trainees were able to perform their job responsibilities of providing
immunization services to the required standards.
In this regard, WHO/NPSP proposed to conduct a study in collaboration with NIHFW to assess
the performance of trained health workers in the same seven states where the PNA study was
conducted. Government of India accorded its approval for conducting an independent study.
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Study limitations:
There are several important limitations of this study which must be mentioned. First, the
sampling methodology employed and size of the sample selected for each study component
does not allow generalization of results to larger sub-populations within individual states.
Likewise, it is not possible to generalize study findings from the seven study states to the rest of
the country. Moreover, without a concurrent comparison state, i.e., a state where training with
the Handbook had not yet taken place, it is impossible to determine whether health worker
performance is attributed to training or other programmatic or non-programmatic factors.
Second, the different sampling methodologies employed by the two studies obviate direct
statistical comparison of results. Thus, a true baseline does not exist and a comparison of
results between the PNA and the HW assessment are illustrative only.
2. Objectives
General Objective:
To study the level of task performance of health workers in providing immunization services
after training with Immunization Handbook for Health Workers and the Facilitator’s Guide (GoI,
2006)
Specific Objectives:
1) To assess the performance (level of knowledge and skills) of health workers after
training in immunization.
2) To seek the opinion of trainers and the trained health workers on course curriculum and
methodology followed during the training.
3) To seek the opinion of supervisors and beneficiaries about the performance and job
behavior of health workers.
4) To find out the non-training issues that would enhance on the job performance with
respect to immunization service provision.
5) To suggest interventions (if any) for improving the performance of health workers
(including modifications in future training courses)
3. Methodology
Study Area:
PNA Study was undertaken in 8 states of the country. The current study proposed to include
seven states as of PNA study i.e. UP, MP, Bihar, Jharkhand, Uttarakhand, Rajasthan and Orissa,
where 50% to 90% training of Health Workers had been completed. Andhra Pradesh was not
included in the study because the health workers training had not started in that state.
13
Study Population:
It comprised of trained health workers (ANMs, LHVs, Male health workers and health
assistants); PHC medical officer; District Immunization officer/Training Coordinator and
beneficiaries / care givers.
Sampling Technique and Sample size:
40 districts were selected from 7 states after listing the district-wise performance of health
workers training for each state. Then colored maps showing the districts with training
performance of <50%; 50 – 80%; 80 – 90% and >90% were prepared. This was followed by
random selection of approximately one sixth of districts in each state from amongst the
districts with more than 80% training performance, covering all geographical areas.
In each identified district, two blocks were selected randomly, one near the district HQ (within
15 kms.) and other distant from the district HQ (more than 15 kms). From each block, four
health workers were selected randomly. Thus, 8 Health Workers were selected (who had
already been trained) from each district.
For the selection of health workers, the block was divided in to 4 zones and one trained health
worker was selected from each zone randomly. The PHC Head Quarter was to be excluded in
the process. On the immunization session day, each team member visited two health workers
for interview and observation during the immunization session being conducted. Then each
team member randomly visited four households with children of 0-2 years of age-group in each
health worker’s area to interview the beneficiaries / caregivers.
Sample size for the study was decided as 40 district training coordinators / DIOs, 80 block
medical officers, 320 health workers and 1920 beneficiaries/care givers.
Data collection schedule:
The data was collected in two phases during June 8-13 and July 13-20, 2009
State (number of
districts) Districts
UP(6) Ambedkarnagar, Basti, Mahoba, Fatehpur,
Jalaun, Jaunpur
Bihar(6) Buxar, Champaran East, Darbhanga, Gaya,
Khagaria, Kishanganj
Phase-1
(14 districts
from 3 states)
Uttarakhand (2) Champawat, Tehri Garhwal
UP (6) Rampur, Moradabad, Lucknow, Saharanpur,
Badaun, Sonbhadra
Jharkhand (5) Bokaro, Gumla, Hazaribagh, Godda, Palamu
Rajasthan (5) Jaisalmer, Dholpur, Pali, Bikaner, Bhilwara
MP(6) Vidisha, Bhopal, Anuppur, Betul, Indore, Ratlam
Phase-2
(26 districts
from 5 states)
Orissa(4) Balasore, Gajapati, Nayagarh, Nuapada
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Data collection Tools:
The following tools were finalized after field testing by 2 member teams in 4 districts of three
states (UP, Bihar and Jharkhand) followed by one day finalization workshop on 15.05.09:
1 Study Tool-1 Interview schedule for District Immunization Officer/ District Training
Coordinator/Trainer
2 Study Tool-2 Interview schedule for Block /PHC Medical officer
3 Study Tool-3 Checklist for Record Study (Look for Monthly Progress Reports of the block for
last 3 months)
4 Study Tool-4 Interview Schedule for Health Worker who received Immunization training
5 Study Tool-5 Checklist for observing the skills of Health Worker in conducting immunization
session
6 Study Tool-6 Checklist for House to house visit to assess knowledge of care givers
Data collection work:
40 study teams, one for each district were identified amongst officers from NIHFW, WHO-NPSP,
WHO-SEARO, WHO-HQ, UNICEF, IMMbasics, Medical Colleges, Training Centers and State
governments. Each team comprised of 2 (4 for Orissa) members. Each team covered one district
in 3 -5 working days. A detailed scheme for data collection and the day wise tasks of study
teams are given at Annex-4.
Before the data collection, one day orientation training was organized at NIHFW on 8th
June and
10th
July, 09 for all the team members. One day debriefing meeting was held after data
collection on 15th
June and 22nd
July, 09 at NIHFW for one member from each team to submit
the filled in data collection tools, the summary of observations and the financial expenditures.
Data Validation and Data Analysis:
Data validation exercise was conducted for all the data collected. This included crosschecking
and matching the data from hard copies in to the soft copies and clarifications sought after
interacting with the investigators. Then, state wise data was compiled and analyzed based on
each objective of the study, leading to preparation of graphs and tables for inclusion into the
report.
4. Study Findings The observations of the study are presented under the following heads-
A. General Profile (Study Tools-1 and 4)
B. Performance (level of knowledge and skills) of health workers after training in
immunization. (Study Tools-4 and 5)
C. The opinion of trainers and the trained health workers on course curriculum and
methodology followed during the training. (Study Tools-1 and 4)
D. The opinion of supervisors and beneficiaries about the performance and job behavior of
health workers. (Study Tools-2 and 6)
E. Non-training issues that would enhance on the job performance with respect to
immunization service provision. (Study Tool-2)
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A. General Profile:
1. Data Collected: Data was collected from 2292 respondents through interviews,
observation of health workers conducting immunization sessions and record study.
(Table 1)
Table 1: Number of respondents of the study
States District
Trainers
Block
MOs
Health
Workers
Exit
Interviews Beneficiaries
Bihar 6 12 48 96 182
Jharkhand 5 10 40 80 160
MP 6 12 44 88 172
Orissa 4 8 32 64 128
Rajasthan 5 10 39 78 154
UP 12 24 96 192 384
Uttarakhand 2 6 14 28 51
India 40 82 313 626 1231
2. Total years in service
of Health Worker:
Majority of Health
Workers had more
than 10 yrs of job
experience as shown
in Figure 1.
3. Number of health
workers posted at the
sub-center: 48% of
the sub centers had
around 2 or more
HWs posted. Around
2/3rd
of the sub
centers in MP, Orissa and Jharkhand and 49% in Bihar had 2 or more HWs. In UP,
Rajasthan and Uttarakhand, majority of sub centers had only one HW.
Figure 1: Total years in service of Health
Worker (n=313)
>10yrs, 71.2%
5-10 yrs,
15.7%
2-5 yrs, 8.9%
<2yrs, 4.2%
16
4. Average population covered by a Health Worker posted at the sub-center: In each of the
states, HWs were covering population much more than the national population norms
for a sub center (5000 in general and 3000 in hilly, tribal and backward areas) as shown
in Figure 2.
5. Health Workers staying at the Sub-center: Overall 32% of HWs were staying at the sub-
centers while in Orissa, 75% HWs stayed at the subcentre. It is shown in Figure 3.
Figure 2: Average population covered by a Health Worker
7303
8782
7960
6282 6424
5119
7996
7092
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
India (n-313) Bihar (n=48) Jharkhand
(n=40)
M P (n=44) Orissa
(n=32)
Rajasthan
(n=39)
U.P. (n-96) Uttrakhand
(n=14)
Figure 3 : Health Workers staying at the Sub-center
32.1
12.5
30.0
39.5
75.0
28.225.0
42.9
0
10
20
30
40
50
60
70
80
90
100
India (n=313) Bihar (n=48) Jharkhand
(n=40)
M P (n=44) Orissa
(n=32)
Rajasthan
(n=39)
U.P. (n-96) Uttrakhand
(n=14)
Perc
en
t
17
6. Any other immunization training received in last three years: 72% of the health workers
had not received any other immunization training in last three years.
7. Percentage of Health Workers trained: All the states had trained majority of HWs (F) and
also HAs (F) though the percentage of trained HA (F) was low in MP, UP and Jharkhand.
HWs (M) were not trained by UP and Jharkhand. HAs (M) were trained only by Orissa
and Uttarakhand. (Table 2)
Table 2: Training status of Health Workers at district level (state wise % trained)
Category of Health
Workers Bihar
Jhark
hand MP Orissa
Rajast
han UP UA India
ANM (HW-F) 87.1 70.7 85.7 94.2 95.5 83.1 89.7 85.7
LHV (HA-F) 69.6 47.9 20.2 84.7 80.1 46.7 100 53.2
HW-M 61.9 14.3 30.5 80.2 59.4 0.0 37.1 43.2
HA-M 2.1 9.4 5.3 39.0 0.0 14.6 100 16.6
Any other category 4.7 58.9 20.5 85.7 86.1 52.5 4.1 39.5
Total 65.2 60.1 59.3 86.2 90.1 65.7 72.6 69.8
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B. Performance (level of knowledge and skills) of health workers after training
in immunization: Each study team member observed the Health Workers at the session site providing
immunization services to at least two beneficiaries. Then, the assessment of the health
worker’s performance was done on each parameter, whether she was competent or
needed to improve. The health workers were also asked questions to assess their
knowledge in immunization.
1. Skills of trained Health Workers in providing immunization services as Compared to
PNA study
• Injection Administration Skills: Significant Improvement was observed in
maintaining aseptic technique, using the correct route for vaccination and
Figure 4 : Injection Administration Skills of trained Health
Workers
17.0
71.0
37.0
67
84.4
74.7
0
10
20
30
40
50
60
70
80
90
100
Maintains aseptic
technique throughout
Injects vaccine using
the correct route for the
vaccine
Allows dose to self-
disperse instead of
massaging
Perc
en
t
PNA-2005 (n=200) HW Trg Evaluation-2009 (n=306)
Figure 5 : Documentation Skills of trained Health Workers
64.058.0
51.0
81.5 84.6
73.2
0
10
20
30
40
50
60
70
80
90
100
Verifies beneficieries
records for vaccination
Checks that it is the
correct date for the
vaccination
Documents each
vaccination correctly
and completely
Perc
en
t
PNA-2005 (n=200) HW Trg Evaluation-2009 (n=306)
19
allowing the dose to self disperse instead of massaging. (Figure 4)
• Documentation Skills: Improvement was observed in verifying the beneficiaries’
records for vaccination, checking for correct date and documenting each vaccine
correctly and completely. (Figure 5)
• Interpersonal Communication Skills: It was still a weak area for the Health
Workers. Though marginal improvement was observed in welcoming
beneficiaries, explaining potential AEFIs and discussing about the next visit,
deterioration was seen in explaining about the vaccines to be given and VPDs
prevented as well as in screening for contraindications.(Figure 6)
State wise comparisons are given in Table-3
Figure 6 : Interpersonal Communication Skills of trained
Health Workers
35.028.0
17.024.0
37.044.2
17.912.9
39.7 38.5
0
10
20
30
40
50
60
70
80
90
100
Welcomes
beneficieries
Explains what
vaccine(s) will
be given
Screens for
contra-
indications
Explains
potential
adverse events
following
immunization
HW discusses
with
beneficieries
/parents about
next visit
Perc
en
t
PNA-2005 (n=200) HW Trg Evaluation-2009 (n=306)
20
Table 3: Skills of HWs in providing immunization services as Compared to PNA study (State wise % of HWs)
Bihar Jharkhand MP Orissa Rajasthan UP Uttarakhand India
Sk
ills
Indicators
PN
A 2
00
5
(n=
47
)
20
09
stu
dy
(n=
48
)
PN
A 2
00
5
(n=
20
)
20
09
stu
dy
(n=
40
)
PN
A 2
00
5
(n=
14
)
20
09
stu
dy
(n=
42
)
PN
A 2
00
5
(n=
15
)
20
09
stu
dy
(n=
32
)
PN
A 2
00
5
(n=
30
)
20
09
stu
dy
(n=
37
)
PN
A 2
00
5
(n=
70
)
20
09
stu
dy
(n=
95
)
PN
A 2
00
5
(n=
4)
20
09
stu
dy
(n=
12
)
PN
A 2
00
5
(n=
20
0)
20
09
stu
dy
(n=
30
6)
Maintains aseptic
technique throughout 21 79.2 15 86.5 14 68.3 20 93.5 43 75.7 7 43.6 0 41.7 17 67.0
Injects vaccine using the
correct route for
vaccine(IM/SC/ID)
70 89.6 55 86.5 92 78 100 96.8 60 86.5 47 80.0 75 75 71 84.4
Inje
ctio
n A
dm
inis
tra
tio
n
Allows dose to self-
disperse instead of
massaging
49 97.9 35 72.2 93 75.6 40 96.8 30 59.5 13 65.9 0 41.7 37 74.7
Verifies beneficiaries
records for vaccination 79 79.2 45 94.3 91 80.0 80 87.1 43 86.5 36 78.7 75 50 64 81.5
Checks that it is the
correct date for
vaccination
79 87.5 40 91.7 63 85.4 72 86.7 53 83.8 44 79.8 50 83.3 58 84.6
Do
cum
en
tati
on
Documents each
immunization correctly
and completely
74 83.3 15 75.7 58 75.6 52 90.3 43 64.9 37 64.5 75 66.7 51 73.2
Welcome Beneficiaries 49 51.1 20 25.8 41 31.4 40 51.6 20 58.8 23 42.2 50 58.3 35 44.2
Explains what vaccines(s)
will be given 60 12.5 10 25.7 58 17.1 52 58.1 10 13.5 7 7.6 0 8.3 28 17.9
Screens for contra-
indications 28 14.9 20 14.3 0 14.6 47 35.5 13 2.7 10 8.7 0 0 17 12.9
Explains potential adverse
events following
immunization
28 47.9 10 41.7 42 56.1 40 67.7 37 48.6 11 19.6 0 0 24 39.7
Inte
rpe
rso
na
l C
om
mu
nic
ati
on
HW discusses with
beneficiaries/parents
about next visit
62 37.5 45 43.2 37 41.5 47 77.4 37 43.2 31 22.6 0 25 37 38.5
21
2. Skills of trained Health Workers in providing immunization services in areas in
addition to PNA study
• Skills in safe injections and waste disposal: Almost all the health workers were
competent in using AD Syringes and new disposable syringe for each
reconstitution. Major improvement is required in use of hub cutters as well as
red and black bags for waste disposal. (Figure 7)
• Post vaccination activities: 56.1% of health workers were updating the
counterfoils after vaccination while only 14.7% were asking the beneficiaries to
wait for 15-30 minutes after vaccination. (Figure 8)
Figure 7 : Skills of Health Workers in providing Immunization
services: Observations at session site (n=306)
98.3 96.4
48.8
35
0
10
20
30
40
50
60
70
80
90
100
Uses AD syringe to
give vaccination
Uses new disposable
syringe for each
reconstitution of the
vaccines
Cuts each AD and
Disposable syringe
with hub cutter
immediately after
use
Used syringes are
kept in red bag for
sending back to PHC
Perc
en
t
Figure 8 : Skills of Health Workers in providing Immunization
services: Observations at session site (n=306)
56.1
14.7
70.4
0
10
20
30
40
50
60
70
80
90
100
Updates counterfoi l of
the beneficiary after
vaccination
Asks the beneficiaries
to wait for 15-30
minutes a fter
vaccination
Immunization schedule
was fol lowed correctly
as checked from 2
beneficiaries cards
Perc
en
t
22
3. Exit interview of the care givers to check the immunization status from the
immunization cards
As shown in Figure 8, 70.4% of the Health Workers were found competent in
providing vaccines according to the immunization schedule and recording them in the
immunization card.
State wise comparisons are given in Table 4 below.
Table 4: Skills of HWs in providing immunization services in areas in addition to PNA
study (State wise % of HWs)
Indicators Bihar
(n=48)
Jhark
hand
(n=40)
MP
(n=42)
Orissa
(n=32)
Rajast
han
(n=37)
UP
(n=95)
UA
(n=12)
India
(n=30
6)
Uses AD Syringe to give
vaccination 100 100 100 100 97 96 100 98.3
Uses new disposable syringe
for each reconstitution. 100 100 96.6 96.3 96.7 92.1 100 96.4
Cuts each AD and Disposable
syringe with hub cutter
immediately after use
21.9 67.6 73.2 93.5 40.5 29.0 41.7 48.8
Used syringes (after cutting the
needle) are kept in red bag for
sending back to PHC
9.4 37.8 51.2 80.6 29.7 23.7 25.0 35.0
Updates the counterfoils after
vaccination 60.0 70.3 46.3 74.2 40.5 59.3 8.3 56.1
Asks the beneficiaries to wait
for 15-30 minutes after
vaccination
6.3 16.2 19.5 51.6 8.1 7.4 8.3 14.7
Providing vaccines according to
the immunization schedule and
recording them in the
immunization card
57.8 76.3 73.7 90.6 72.2 65.6 66.7 70.4
4. Knowledge of the trained health workers in immunization During interview, health
workers were asked open ended questions; their responses were noted and judged as
Figure 9 : Knowledge of the trained Health Workers
(n=313)
50.2
83.4 85.3
35.1
94.6 92.3 90.4
0
10
20
30
40
50
60
70
80
90
100
Vaccination of
a 16 months
old child
Vaccinat ion of
a child coming
after a gap of
6 months
Dose of Vit A M ethods of
Tracking drop-
out children
Route & site of
BCG
Route & site of
DPT
Route & site of
M easles
Perc
en
t co
rrect
resp
on
ses
23
correct if they matched with the correct answers. Their knowledge regarding tracking
of drop outs and the vaccination schedule of children coming late for vaccination was
found to be poor. (Figure 9). Table 5 gives the state wise comparisons.
Table 5: Knowledge of the trained health workers in immunization (State wise % of HWs
with correct responses)
Questions Bihar
(n=48)
Jhark
hand
(n=40)
MP
(n=44)
Orissa
(n=32)
Rajast
han
(n=39)
UP
(n=96)
UA
(n=14)
India
(n=31
3)
If a child comes for vaccination
for the first time at 16 months of
age, what should be given?
58.3 67.5 31.8 75.0 46.2 40.6 50.0 50.2
A child received BCG, DPT1 and
OPV1 at the age of 1 and half
months and then comes again
after a gap of 6 mths. Which
vaccines will you give?
89.6 97.5 65.9 93.8 71.8 89.6 42.9 83.4
Dose of Vit A solution for a child
above 1yr of age? 91.7 95.0 75.0 96.9 82.1 81.3 76.9 85.3
How can you track drop out
children 27.1 40.0 20.5 75.0 46.2 22.9 57.1 35.1
What will you do if a child comes
with mild fever, pain and
swelling at the site of injection
87.2 55.0 65.9 78.1 87.2 56.3 76.9 69.1
What is the route and site for
administration of BCG 93.8 97.5 90.9 100.0 89.7 94.8 100.0 94.6
What is the route and site for
administration of DPT 97.9 100.0 84.1 96.9 92.3 88.5 92.3 92.3
What is the route and site for
administration of Measles 95.8 97.5 86.4 100.0 76.9 91.7 69.2 90.4
5. Reporting of AEFIs and VPDs
Monthly progress reports of last 3 months from the health workers were checked at
the PHC to see if they had reported any AEFI or VPD in the last 3 months. There was
either no reporting or very poor reporting of these across all the states. (Table 6)
Table 6: Reporting of VPDs and AEFIs from PHCs (State wise % of PHCs)
Indicators Bihar
(n=12)
Jhark
hand
(n=10)
MP
(n=12)
Orissa
(n=8)
Rajast
han
(n=10)
UP
(n=24)
UA
(n=6)
India
(n=82)
More than 80% of planned
sessions held 75.0 90.0 100.0 100.0 100.0 79.2 66.7 86.4
Any AEFI reported in last 3
calendar months 0.0 0.0 27.3 25.0 0.0 4.2 0.0 7.4
Any VPD reported in last 3
calendar months 25.0 30.0 18.2 37.5 20.0 8.3 16.7 19.8
24
6. Performance of trained health workers at the session site
86% of the sessions were being held as per the RI microplans. Due list of beneficiaries
was available with 60% of health workers. However, less than half of HWs in UP, Bihar
and Uttarakhand had the due lists available with them. 76% of Health Workers had
kept the reconstituted vials in shade on the ice packs and 79% wrote the time of
reconstitution on BCG and Measles vials.
7. Examples of improvement in immunization practices after training as informed by
HWs (Figure 10)
70% of the HWs reported improvement in their injection techniques and site of
injection after the training. Only 4% reported improvement in their communication
and social mobilization activities; same number reported improved knowledge in
AEFIs.
8. Any new initiatives/activities conducted to improve community involvement after
training (Figure 11)
43% HWs did not respond. 26% reported better coordination with ASHAs, AWWs and
other volunteers. 1/4th
informed holding monthly meetings with different
stakeholders (community, parents, members of SHGs, PRI representatives, etc) while
only 7% HWs reported using inter personal communication to convince parents.
Figure 10 : Improvement in the immunization practices of
HWs after training (n=313)
3.8
3.8
9.6
11.8
14.4
14.7
21.1
21.7
70
Contraindications/AEFIs
Communication and mobilization
M icroplanning and conduction of sessions
Immunization schedule and vaccine dosage
Safe injections
Tracking, data interpretation, recording and reporting
Cold chain maintenance in session
Safe disposal of injection waste
New injection techniques and sites
25
Figure 11 : New initiatives/activities conducted to
improve community involvement after Training (n=313)
7
8.6
23.6
26.2
43.1
Influencing parents through
better IPC
Others
M onthly meetings held with
different stakeholders
Better coordination with
ASHAs/AWWs/other
volunteers
No response
26
C. The opinion of trainers and the trained health workers on course
curriculum and methodology followed during the training
District Training coordinator/DIO/Trainer were interviewed and the records and facilities
were observed to assess the quality of training provided to the health workers. Health
workers were also interviewed to find out their opinion on the quality of training and their
suggestions for improving future training.
1. Opinion of trainers about the quality of Training Courses conducted:
• Average batch size for HW training was found to be 26, much more than the
norm of 15 in each of the states (Figure 12)
• Last training batch was conducted 1-2 years back as reported by 57.5% of
trainers. However, 37.5% reported last training batch within one year.
• Average number of TOT trained trainers available in the districts for HW
training was 5 but only 3 in Bihar and Uttarakhand. (Figure 13)
Figure 12: Average number of Trainees per batch
2627
23
26 2625
26
20
0
5
10
15
20
25
30
Indi
a (n
=40)
Bihar
(6)
Jhar
khan
d (5
)
MP (6
)
Oris
sa (4
)
Raj
asth
an (n
=5)
UP (n
=12)
Uttr
akhan
d (n
=2)
27
• Average number of trainers involved in HW training on both days was only 2 to
3 in 64% of the districts as informed by the trainers. (Figure 14)
• Training was residential only in 35% of the districts. Orissa had made
residential arrangements in all the districts; UP and Rajasthan in around 40% of
the districts while Bihar in one third. No residential arrangements were made
by Jharkhand, Uttarakhand and 5 out of 6 districts in MP.
• All the Trainers except in Jharkhand and Uttarakhand reported that they had
organized field visits during training.
Figure 13 : Number of TOT trained trainers available in the
districts
5
3
7
5
8
5 5
3
0
1
2
3
4
5
6
7
8
9
10
Indi
a (n
=40)
Bihar (
6)
Jhark
hand (5
)
MP (6
)
Oriss
a (4)
Rajas
than
(n=5)
UP (n
=12)
Uttra
khand
(n=2
)
Figure 14 : Involvement of Trainers on both days of
Training
64
.1
10
0
10
0
66
.7
50
40
41
.7
10
0
35
.9
33
.3
50
60
58
.3
0102030405060708090
100
India
(n=40)
Bihar
(n=6)
Jhark
hand (n=5)
MP (n
=6)
Oris
sa(n
=4)
Rajast
han (n=5)
UP (n
=12)
Utt
arak
hand (n=2)
Perc
en
t
2 to 3 Trainers 4 or More Trainers
28
• All the training centers distributed Immunization Handbooks in local language,
70% distributed handouts from the facilitators’ guide and 80% gave certificates
to the participants.
• Pre/post test was done by all and feedback received by 80% of the training
centers.
• Based upon the feedback of initial few training sessions, trainers arranged for
flip charts, black boards, functional hub cutters and cold chain equipment
before hand for next batches; LCD projector was used for immunization film
and more focus was given to demonstration of safe injection practices; More
emphasis was laid on practical demonstration of injection practices and the
participants were taught on preparing list of due beneficiaries.
2. Knowledge and Skills of trainers in immunization training of health workers: 5 questions
were asked to all the district trainers to demonstrate their training skills in areas of cold
chain, injection administration, injection safety, AEFI, increasing immunization coverage
and tracking of drop outs. Based on the responses, performance of each trainer was rated
as excellent, good or average.
Trainers’ performance was poor in AEFI management and tracking of drop outs in Bihar,
Jharkhand, MP and UP. In other areas, it was variable. Orissa and Rajasthan performed
better as compared to other states in all the parameters. (Table 7)
Table 7: State wise % of trainers with excellent and good performance in training skills
Indicators Bihar
(n=6)
Jhark
hand
(n=5)
MP
(n=6)
Orissa
(n=4)
Rajast
han
(n=5)
UP
(n=12)
UA
(n=2)
India
(n=40)
How would you describe and
demonstrate "Conditioning of
ice-packs" to HWs 80 75 66.6 100 100 45.5 0 69.7
Demonstrate use of AD
syringes for giving DPT injection
to an infant
100 80 83.3 75 80 91.7 50 85
Demonstrate use of Hub-cutter
and safe waste disposal 100 20 66.6 100 100 45.5 100 68.4
How did you train HWs on
management of AEFIs 33.4 40 60 75 60 55.5 50 52.8
How did you train HWs on
"increasing immunization
coverage" and tracking of drop-
outs
33.3 40 16.7 100 75 45.5 100 50
3. Problems faced by the Trainers during training and Suggestions for future training
• 20% of the respondents cited no proper training facility as a major problem.
Others informed about higher batch size, shortage of training materials, less
time for training and lack of transport arrangements, etc.
29
• Course contents were adequate and rationally developed according to 65% of
respondents. One fifth felt that session on preparing due list of beneficiaries
and VHNDs could be included.
• Training methodology was well designed and directed to the participants
according to half of the respondents. One forth felt that more field based
sessions with practical demonstration to be included.
• Facilities at the Training center: Proper training and transport facility at district
level was required according to majority of the respondents. Training centre
must be supported with adequate infrastructure.
• Number of Trainers: 3-4 trainers were adequate according to 2/3rd
of the
respondents. 50% felt that few additional trainers should be trained to take
care of absence of trainers.
• Funds must be made available for the rest of the batches, so that the
remaining HW (M and F) are trained in the districts.
• Other support required: One sixth felt that training should be made more
practical and extended to 3 days. Honorarium of the trainers must be
increased. Training of Data Handlers and Cold Chain Handlers must be tagged
with HW training. Refresher training must be planned. Training of AWW/ASHA
must also be done along the same lines on RI. State level guidelines must be
included in the ANM module locally
• Areas to be added in the Handbook: Few areas suggested for addition were
details on VPDs, Communication skills, Details on newer vaccines, Refresher
package, newer guidelines on RI, Vaccine management and Sessions on local
formats.
• Areas to be deleted: None was the reply from all the respondents.
• Areas to be modified: None was the reply by half of the respondents. 10%
suggested modifying the formats in local language. 2.5% suggested that Cold
chain unit could be reduced and case studies added.
4. Facilities available at the Training Centers:
20% of the districts had no training facility. 80% of the districts had training centers and
class rooms but only half had hostel rooms and transport facilities. There were interstate
variations as shown in Table 8.
Table 8: State wise percentage of training centers with available training facilities
Training facilities Bihar
(n=6)
Jhark
hand
(n=5)
MP
(n=6)
Orissa
(n=4)
Rajast
han
(n=5)
UP
(n=12)
UA
(n=2)
India
(n=40)
No training facility available 50.0 20.0 16.7 0.0 0.0 8.3 100.0 20.0
Classroom 50.0 40.0 100.0 100.0 100.0 91.7 50.0 80.0
Hostel-rooms 16.7 20.0 50.0 50.0 40.0 83.3 0.0 47.5
Transport 16.7 20.0 66.7 75.0 60.0 75.0 0.0 52.5
5. Opinion of Health Workers about the quality of Training Courses attended:
30
• Duration of training: 56% of HWs found the duration of training to be
adequate.
• Field visit organized: 68% of the health workers (10% in Jharkhand) reported
that field visit was organized during training.
• Injections practiced: During field visits, only 38% of the health workers got
opportunity to practice injections (12.5% in Bihar and 0 in Jharkhand)(Figure
15)
• Immunization film was shown during training as reported by 64% of HWs (20%
in Jharkhand).
• Referred the Immunization Handbook after training and availability at session
site: 74% of HWs referred the Immunization Handbook after training but it was
Figure 15 : Field Visit Organized – Injections Practiced
68.362.5
10
63.6
100
66.7
88.5
61.5
37.8
12.5
0
36.4
71.9
53.8 50
30.8
0102030405060708090
100
India
(n=313)
Bihar
(n=48)
Jhark
hand (n=40)
MP (n
=48)
Oris
sa(n
=32)
Rajast
han (n=39)
UP (n
=96)
Utt
arak
hand (n=14)
Perc
en
t
Field Visit organized Injections practiced during field visits
Figure 16 : Referred Immunization Handbook after
training and Handbook available at session site
73.677.8 76.9
54.5
100
71.8 72.6
61.5
13.96.5
15.4 11.9
46.9
12.8 8.80
0102030405060708090
100
India
(n=313)
Bihar
(n=48)
Jhark
hand (n=40)
MP (n
=48)
Oris
sa(n
=32)
Rajast
han (n=39)
UP (n
=96)
Utt
arak
hand (n=14)
Perc
en
t
Refer immunization handbook after training Available at Session Site
31
only available at 14% of the session sites. (Figure 16)
• Sessions liked best: Demonstration and practice of injection techniques were
liked by 1/3rd
of HWs. Other responses were watching the film on organizing
and conducting vaccination sessions, sessions on National Immunization
Schedule, cold chain, injection safety and waste-disposal.
• Sessions liked least: HWs could not recall any sessions which they did not like.
• Suggestions to improve the Immunization handbook: No specific suggestions
were given to improve the Immunization handbook. V. few suggested for more
pictures and diagrams.
• Boarding and lodging facilities at the training center: 1/3rd
of the HWs did not
respond to the question. Almost 1/3rd
of the HWs reported that stay
arrangements were either good or OK. 20% reported that no facilities were
provided for stay during the training. 20% opted to stay at a relatives/ friends
house. 4% reported that the facilities provided were not up to the mark.
• Difficulties faced during training: 90% of HWs did not face any difficulties. Only
6% complained that no arrangements for practical training were made.
• Need further training in immunization and the areas: 73% of HWs felt the need
for further training in immunization. Areas for training were suggested as
hands on practice of injection techniques by 1/4th
of the HWs; updates on
vaccines, cold chain maintenance and microplanning by around 10% of
respondents.
• Training methodology suggested: 70% HWs suggested field visits as the
methodology; 51% suggested films; 36% role-plays while 30% group work and
lectures.
• Suggestions for improving future training: 43% of the respondents suggested
that future trainings be more practical oriented with field visits and hands-on-
practice. Refresher training at least once a year was suggested by 17% of HWs.
11% wanted training for longer duration. 7% wanted more film shows and
more use of audio-visual media during the training.
D. The opinion of supervisors and beneficiaries about the performance and
job behavior of health workers
The supervisors of HWs at the PHC and the beneficiaries/caregivers were interviewed
through house to house visits to assess the job behavior of the trained health workers.
1. Areas in which Supervisors noted change in performance of Health Workers after training
32
18% of respondents noted improved Tracking of drop-outs by HWs; 16% noted better
recording and reporting; 15% noted better injection technique and safety; 7% noted
improved immunization waste disposal; 4% improved knowledge of microplanning and
2.5% better cold chain maintenance and use of Hub Cutters. (Figure 17)
2. Knowledge of Care givers of children in the age group of 0-2 years: (Figure 18)
93% of the caregivers were aware about the place of immunization session; 3/4th
were
reminded for vaccination prior to vaccination day and 72% knew about the site of
vaccination of their child; 71% knew about minor adverse events following immunization
and 70% had their children received age appropriate vaccines; 56% knew what to do in
case minor adverse events following immunization occur and 49% knew when to go for
the next due vaccine for their child. State wise comparisons are given in Table 9.
Figure 17 : Supervisors noted change in the performance
of HWs after training (n=82)
2.4
2.4
3.7
7.3
14.6
15.9
18.3
Us e of Hub Cutters
better cold cahin maintenance
improved knowledge of mi croplanning
Immunization was te dis posa l
Better injection technique and s afety
Better recording and reporting
Tracking of drop-outs
Figure 18 : House to House visits
Knowledge of Care givers (n=1231)
75.1
48.5
69.8
55.7
71.1
71.8
93.2
Reminded for vaccination prior to vaccination
day
Knowsledge about when to go for next due
vaccines
Chi ld received age appropriate vaccines
Knowledge about handl ing minor AEFIs
Knowledge about minor AEFIs
Knowledge about chi ld's vaccination s i te
Awarenes s about place of Immunization
33
Table 9: Knowledge of care givers during house to house visits (State wise %)
Indicators Bihar
n=182
Jharkh
and
n=160
MP
n=172
Orissa
n=128
Rajast
han n=
154
UP
n=384
Uttara
khand
n=51
India
n=123
1
Awareness about the
place of immunization 92.9 96.9 93 98.4 89.6 90.6 100 93.2
Knowledge about child’s
vaccination site
65.4 74.4 60.5 85.2 78.6 68.3 96.1 71.8
Knowledge about minor
AEFIs
70.9 62.5 64 95.3 77.8 65.6 84.3 71.1
Knowledge of what to do
in case minor AEFIs occur
52.7 46.3 53.5 88.3 49.7 53.8 52.9 55.7
Child received age
appropriate vaccines
52 75 72.7 86.7 59.7 70.8 86.3 69.8
Knowledge about when
to go for next due
vaccines of the child
34.4 50.6 59.3 68 52.6 37 80.4 48.5
Reminded for vaccination
prior to vaccination day
71.5 85 83.7 96.9 69.5 63.7 74.5 75.1
E. Non-training issues that would enhance on the job performance with
respect to immunization service provision Interview of the PHC medical officers and observation of RI services at the PHC brought
out some important non training issues which influence the job performance of the health
workers.
1. Routine Immunization services available at the PHC (Figure 19)
Map of the catchment area was available in only 39% of the PHCs. Estimation of
beneficiaries and logistics as a part of Microplan was done by 60.5% of PHCs. Roster of
HWs was available at 88% of the PHCs. Alternate Vaccine Delivery plan was available
in 60.5% of the PHCs (36.4% in MP). No specific reason was mentioned by majority for
not having AVD plan. 5% cited lack of funds and 4% lack of awareness about this
system. State wise comparisons are given in Table 10.
Figure 19 : Routine Immunization Services available at the PHCs
(n=82)
37
3.7
60.5
87.5
60.5
39
Stock-outs or shortage (vaccines, syringes etc.)
reported in last 3 months
Is Coverage monitoring chart/drop out chart
displayed at the PHC
Alternate vaccine delivery plan to supply the
vaccines and logistics to session sites?
Roster of health workers
Estimation of beneficiaries and logistics for
current year
Map of catchment area including all sub-centers
and distances from vaccine storage point
34
2. Coverage monitoring chart/drop out chart was displayed only at 3.7% of the PHCs
Table 10: Immunization services available at the PHC (State wise %) RI Services at PHC
Bihar
(n=12)
Jharkh
and
(n=10)
MP
(n=12)
Orissa(
n=8)
Rajast
han
(n=10)
UP
(n=24)
UA
(n=6)
India
(n=82)
Map of catchment area
including all sub-centers
and distances from
vaccine storage point
25.0 30.0 33.3 62.5 50.0 41.7 33.3 39.0
Estimation of
beneficiaries and logistics
for current year
25.0 50.0 75.0 75.0 80.0 75.0 0 60.5
Roster of health workers 83.3 100.0 83.3 75.0 80.0 100.0 66.7 87.8
Alternate vaccine delivery
plan to supply the
vaccines and logistics to
session sites?
66.7 90.0 36.4 50.0 70.0 70.8 0.0 60.5
Coverage monitoring
chart/drop out chart
displayed at the PHC
0.0 0.0 0.0 25.0 0.0 4.2 0.0 3.7
Stock-outs or shortage
(vaccines, syringes etc.)
reported in last 3 months
16.7 60.0 25.0 50.0 20.0 34.8 83.3 37
Disposal pit used for
immunization waste
disposal
91.7 40.0 63.6 62.5 40.0 45.8 33.3 54.3
3. Stock-outs or shortage (vaccines, syringes etc.) in last 3 months was reported by 37%
of PHCs covering all the states. 15% reported stock out of BCG vaccine, 9% reported
measles, 7% reported 0.1 ml ADS, 6% reported for DT, TT and Measles vaccines.
Figure 20 : Methods used for disposal of sharps at the PHC
54.3%
3.7%
42.0%
Disposal Pit
Other Means
No proper method
35
Alternate Vaccine Delivery System was working very well in Bihar and Jharkhand
4. Methods used for disposal of disinfected sharps (cut needles, broken vials & ampoules)
(Figure 20)
Though disposal pits were used in 54% of PHCs, only 30% were practicing disinfection.
No proper method was available for waste disposal in 42% of the PHCs. Burial or
burning was practiced by 22% of the PHCs as elicited on asking open ended question.
5. Supervisory visits undertaken to SC/Session site during last 3 months: On an average,
Medical officers conducted 11 visits (4/month) and other supervisors of HWs
conducted 22 visits (7/month) in the last three months. But no records were available
at the PHC to support the supervisory visits in 45% of the PHCs and Supervisory
checklists/reports were available only at 27% of the PHCs. (Figure 21)
6. Cold chain and logistics management at PHC
Vaccines were delivered through Alternate Vaccine Delivery System in 71% of session
sites (100% in Bihar and 95% in Jharkhand). Conditioned ice packs were available in
the vaccine carrier at 84% of session sites and VVM was found in correct stage in 98%
of session sites. Ice packs were conditioned correctly at 48% PHCs; temperature log
books were correctly maintained at 64% PHCs; stock registers were maintained
correctly at 72.5% of the PHCs. VVM was found in usable stage in 96.3% of PHCs.
7. Availability of cold chain and injection safety logistics at the PHC and session site
Functional DFs were available at 80%; ILRs at 78%; thermometers at 91% and voltage
stabilizers at 82% of PHCs; Indent forms were available in 51% of PHCs and supply
vouchers in 63% of PHCs. Functional hub cutters were available in 54% (21% in UP and
Figure 21: Records available at the PHC to support the
supervisory visits (n=82)
45
2724
13
0
10
20
30
40
50
60
70
80
90
100
No Records Supervisory
checklist/reports
Movement Register Log book
Perc
en
t
36
25% in Bihar) and bleaching solution in 38% of PHCs. At the session site, availability of
functional hub cutters (53%), red bags (36%) and black bags (32%) was poor.
8. Tracking tools available at the PHC and session site
Immunization cards were available at 86% of session sites and 83% of PHCs,
Immunization registers were available in 77% and Tracking bags in 49% of the PHCs.
Coverage monitoring charts were available in only 3.7% of the PHCs (25% in Orissa).
How monitoring and supervision improved the performance of HWs
(Orissa - Success story) Three Govt. medical colleges were assigned the monitoring of HW training in addition to
the monitoring of the Immunization program on a regional basis. Community Medicine
faculties from these medical colleges were trained as the key master trainers. They in
turn trained the district trainers at zonal level and only those trainers with good training
skills were selected for training the HWs.
15% of the HW trainings were monitored and supportive supervision was provided. Each
monitor (medical college faculty) stayed in the district at the training venue for entire 2
days of the training and wherever s/he identified severe gaps, s/he facilitated the session
and provided supportive supervision to the district facilitators and visited again after 2-3
months when the same facilitators conducted the training. Same monitors also visited
the field session sites, assessed the skills of health workers and gave appropriate
feedback to the respective district trainers. Districts with poor performance received a
letter directly from the medical college with a copy marked to NRHM-MD, Director FW
and UNICEF. Mid course corrective actions based on monthly monitoring reports were
undertaken at several places. Quarterly review meetings are held with all the monitors at
the state level. The reports are shared and appropriate actions taken by the state
through DPMU.
37
5. Major conclusions and Recommendations
1. Training
All states with the exception of Jharkhand have trained more than 80% of female health
workers (ANMs) on vaccination of children and pregnant women, while the newly recruited
contractual female health workers and other categories as male health workers, health
assistants, cold chain handlers, data handlers etc are still left to be trained for their specific
tasks.
State governments need to release funds to the districts to continue the in-service training
for all health workers including HW (male), HA (male),HA (female), cold chain and data
handlers in their specific tasks at PHC and District level as well as newly recruited
contractual health workers.
Sixty-five percent of trainers deemed the course contents were adequate and rationally
developed. Suggested topics to be included in the Handbook were details on VPDs,
communication techniques and details on newer vaccines. One in four of those interviewed
felt that more field based sessions with practical demonstration of preparing due list of
beneficiaries and VHNDs should be included.
Training material should be updated based on recent policy changes and more emphasis is
required on improving communication skills (in the handbook as well as in the facilitators’
guide).
Eighty percent of the districts had training centers and class rooms available, however, only
half had hostel rooms and transport facilities. Residential arrangements were made by 35% of
the districts.
There is need to establish or strengthen the logistical capacity and infrastructure of training
facilities and residential arrangements need to be made in each district for training.
The average batch size for HW training was 26, well above the norm of 15. During field visits,
only 38% of the health workers reported having the opportunity to practice injections. While
all training centers distributed Immunization Handbooks in local language, only 64% of HWs
reported viewing the Immunization film during training.
States need to enforce guidelines for a batch size of 15 and at least 3 trainers for each
training course. Hands-on opportunities must be provided to the trainees by taking the
participants in small batches to 3-4 different session sites. Greater oversight of training
sessions by state and district officials as well as partners is necessary.
Sixty percent of health workers reported that only 2 to 3 trainers were involved on both days
of training. Trainers’ skills were found to be weak in conditioning of ice-packs, use of
hubcutters, AEFI management and tracking of drop outs. Trainers from Orissa and Rajasthan
performed better as compared to the other states on all parameters.
States need to train more trainers to ensure adequate number of trainers in all the districts.
Trainers’ skills need to be evaluated and strengthened through annual refresher trainings.
38
One district level officer should be designated as nodal officer for coordinating the
immunization training of all health functionaries.
2. Performance of health workers after training in Immunization
Injection administration skills of Health Workers appear to have improved since the PNA
study. 85% of HWs were injecting vaccine using the correct route per antigen; 75% were
allowing dose to self disperse instead of massaging and 67% were maintaining aseptic
technique. 98% of the health workers were found competent in using ADS and 96% in using
new disposable syringe for each reconstitution. However, only half of observed health
workers cut each syringe with hubcutters immediately after use.
Regular training and retraining of health workers in RI is required every year. There is a
need to provide hands on training to health workers to practice injection administration
techniques.
Documentation (recording and reporting) skills of health workers also improved after training
as compared to the baseline PNA study with 73% of all health workers documenting each
vaccination correctly and completely. However, reporting of VPDs and AEFIs was found to be
very poor across all the states.
HWs need to be supervised to ensure that they prepare the due lists, fill counterfoils and
update the Immunization registers regularly. HWs should be sensitized and encouraged for
reporting of VPDs and AEFIs.
Interpersonal Communication skills of health workers were found to be weak even after
training. 44% were welcoming beneficiaries; 40% were explaining potential adverse events
following immunization and 39% were discussing with beneficiaries/parents about the next
visit. Only 18% were explaining what vaccines would be given and the VPDs prevented; 13%
were screening the beneficiaries for contraindications and 15% were asking the beneficiaries
to wait for 15-30 minutes after vaccination.
Need to improve communication skills and technical knowledge of the health workers by
ensuring supportive supervision and on the job training by MO/PHC during immunization
sessions. As a constant reminder for health functionaries, key IPC messages in local
language should be displayed at the session site.
While 93% of beneficiaries/caregivers knew about the place of immunization session, only
49% caregivers knew when to go for next due vaccine. Three-fourths of care givers were
reminded for vaccination prior to vaccination day by the social mobilizer and 70% children
had received age appropriate vaccines.
IEC and IPC in the community need to be improved. HWs need to share the due list of
beneficiaries with ASHA/AWW for tracking of drop-outs. ASHAs need to be trained for
better community mobilization especially in the resistant group.
3. Immunization Program support to HWs
Coverage / Microplanning
39
Eighty six percent of the sessions were being held as per the RI microplans; however, a map
of the catchment area was available in only 39% of the PHCs. Estimation of number of
beneficiaries and logistics as a part of microplan was limited (61% of PHCs). Though roster of
HWs was available at 88% of the PHCs, the Alternate Vaccine Delivery plan was available in
only 61% of the PHCs.
Proper Microplans with maps are required so that no area is missed. Maps showing the
subcentres, distance of session sites from ILR points and alternate vaccine delivery plan
need to be displayed at each PHC.
Cold chain and logistics management
Designated and trained cold chain handlers were not available at the PHCs. Vaccines were
delivered through Alternate Vaccine Delivery System to 71 % of session sites. 73% of PHCs
were correctly maintaining the stock registers; 64% were correctly maintaining the
temperature log books and only 48% were conditioning the icepacks correctly. Stock-outs or
shortage of vaccines or syringes in last 3 months were reported by 37% of PHCs covering all
the states.
Twice daily recording of temperature in the log books needs to be monitored. Urgently
designate and train the cold chain handlers in their specific tasks. Nonfunctioning cold chain
equipment needs to be repaired or replaced. Ensure regular supplies of immunization cards,
registers, tracking bags and coverage monitoring charts.
Injection safety and waste disposal
Forty nine percent HWs were cutting AD syringes immediately after use and 35% were using
red bags to keep cut AD syringes. Availability of functional hub cutters at PHC (54%) and
Session site (53%) was poor. Availability of red bags (36%) and black bags (32%) was also poor
at session site. Though disposal pits were made by 54% of PHCs, disinfection was practiced
only by 30% PHCs; syringes and needles were thrown into these pits meant for sharps only;
burning and burying of the immunization waste was also practiced. Only 68% of the trainers
had good knowledge of the use of hub cutters and safe disposal of immunization waste.
States need to establish a system of collection of segregated waste from session site to PHC
for disinfection and proper disposal; ensure regular supplies of hubcutters, bleaching
solution, red and black bags and also construction and proper utilization of waste pits for
disposal of sharps. Monitoring and supervision by medical officers needs to be ensured.
AEFIs
Only 53% of the trainers of health workers had good knowledge on the management of AEFIs
and 69% of the health workers knew proper treatment of minor AEFIs. However, only 40% of
health workers explained potential AEFIs to care givers. Only 7% of the PHCs had reported
AEFIs in the MPRs of last three months preceding the study.
Training surrounding all aspects of AEFI needs to be strengthened to ensure that medical
officers regularly sensitize the health workers on reporting and management of AEFIs and
that HWs explain potential AEFIs and their management consistently to each beneficiary /
caregiver.
Tracking and mobilization of beneficiaries
40
During observed sessions, only 39% of health workers discussed with beneficiaries /parents
the date of the next visit. Approximately 30% of beneficiaries did not receive age-appropriate
vaccinations. Only 4% PHCs displayed coverage monitoring charts and only 50% of trainers
had adequate knowledge about tracking of dropouts.
Preparing due lists, updating counterfoils and using tracking bags should be standardized
for tracking beneficiaries. HWs need to update immunization register by including
information from the records of AWW/ASHA as well as new born tracking booklets of SIAs.
Coverage monitoring charts should be displayed in every PHC and sub center and this should
be ensured through supportive supervision and on the job training by MO/PHC during
immunization sessions.
Monitoring and Supervision
Though medical officers of the PHC reported monitoring on an average 4 session sites per
month and other supervisors monitored around 7 session sites per month during last 3
months, no records to support the supervisory visits were available in 45% of the PHCs. Fifty
six percent of health workers reported that MO had visited their session sites in the last 3
months while 63% reported the visit of other supervisors.
Provide mobility support to medical officers for the field visit and supervision. Train all
supervisors on monitoring and supervision of all the health functionaries involved in
immunization services. The monitoring by BLOCK TEAM and by DISTRICT TEAM should be
made mandatory; this needs specific guidelines and tools to be prepared and shared with all
states and districts.
Way Forward
• Update training materials at national level for training the health workers, cold chain and
data handlers in the states.
• Use innovative training methodologies e.g. developing web based training packages for e-
learning, videos etc.
• States need to provide refresher training to the trainers as well as all health functionaries
every year and orientation/induction training for the new staff. Annual State PIPs under
NRHM need to include all the immunization training related activities.
• Regular monitoring to understand weaknesses and tailored supportive supervision of all
health functionaries is required to reinforce training and improve quality of services and
ultimately immunization coverage rates.
41
Annex 1: State wise summary of observations and suggestions by the study
teams
1. Bihar
(Buxar, Champaran East, Gaya, Darbhanga, Kishanganj, Khagaria)
Areas Major Observations Recommendations
Qu
ali
ty o
f T
rain
ing
1. Funds not received for last one year to train the
backlog of contractual and newly recruited
Health Workers
2. Residential arrangements were made only in 2
out of 6 districts
3. Training facility was available in 50% of the
districts
4. Hands on skill practice was not provided at any
of the districts
5. Training batch size was of 25-30 participants, 2
batches trained together at some places
6. Only 3 district trainers were available in some
districts.
1. Need to establish or strengthen the training
facilities for providing regular in-service
training to the health service providers in each
district.
2. Pre-Training venue assessment must be done
by the state/district to ensure proper venue
site/arrangement. Gaps noted during the
exercise must be addressed by the State /
Districts
3. Funds with revised guidelines for batch size of
15 HWs to be trained by 3 trainers/batch need
to be sent from the state to the districts
4. Residential arrangements need to be made in
each district for training.
5. Hands on skill practice opportunity must be
provided to the trainees in small batches.
6. Training of more trainers in each district to be
considered.
7. Training of cold chain and data handlers, male
HW and HA, left over ANMs and LHVs is
required.
8. District Level Monitoring of the training
sessions must be done in future training
programmes with partners help
42
Areas Major Observations Recommendations
Imm
un
iza
tio
n P
rog
ram
su
pp
ort
to
HW
s
1. Excellent functioning Alternate Vaccine
Delivery system, adequately staffed sub
centers and PHCs, Medical officers conduct
monitoring of Muskan sessions at some places.
2. Map of the area with sub-centers and AVD
plan was not available at majority of the PHCs.
3. Nonfunctional and Condemnable cold chain
equipment and vehicles were lying in the
districts and blocks.
4. Acute shortage of functional cold chain
equipment, hub-Cutters, thermometers and
immunization cards
5. Poor maintenance of records for cold chain
and logistics. Temperature log books were not
available.
6. Cold chain handler not designated and not
trained at most of the blocks.
7. Poor waste management-no hubcutters,
bleaching solution and immunization cards. All
syringes and needles were put into the
disposal pit.
8. Poor Supervision and Monitoring by District
and Block Officials. No records of supervision
by MO were available.
9. No reporting of AEFIs at any of the blocks
1. Improve micro-planning
2. Condemnation and replacement of non
functional cold chain equipment is urgently
required.
3. Supply hubcutters, cold chain equipment and
immunization cards.
4. Improve waste management by proper
monitoring from district level.
5. District and Block Level Supervision needs
improvement.
6. Need to train the medical officers, cold chain
handlers and data handlers
7. Sensitization of health workers on reporting of
VPDs and AEFIs is required.
8. Training of all categories of supervisors is
required on monitoring and supervision of
health functionaries involved in immunization
services.
Pe
rfo
rma
nce
of
HW
s
1. Majority of HWs were competent. Sufficient
numbers available for social mobilization.
2. Due list of beneficiaries was not available.
3. Map of the areas were not displayed.
4. Key IPC messages were not given.
5. Poor tracking of beneficiaries.
6. No Immunization cards and hubcutters
available.
7. Waste disposal was not as per guidelines.
8. Injection administration skills and screening
for contraindications need improvement.
1. Provide supervision and on the job training to
HWs sp. For micro-planning, vaccination
techniques, IPC, tracking and recording and
reporting etc.
2. Train HWs to prepare due list of beneficiaries
for every session.
3. Provide immunization cards, PCM, functional
hubcutters, red and black bags and tracking
bags to the HWs.
4. Ensure HWs give key IPC messages to the
beneficiaries – display such a poster in Hindi at
each session site.
Co
mm
un
ity
resp
on
se
1. Community is very receptive and acceptance
of RI services is good
2. Dependent upon AWW/ASHA for the
vaccination
3. Majority did not know about next date of
vaccination
1. ANM, in coordination with AWW and ASHA,
needs to improve IPC and tracking of
beneficiaries.
2. ASHAs need to be trained for better
community mobilization.
43
2, Jharkhand
(Bokaro, Gumla, Hazaribagh, Godda, Palamu)
Areas Major Observations Recommendations
Qu
ali
ty o
f T
rain
ing
1. Trainings were held at block PHCs by MOs
trained at District level.
2. Field visits to practice injection techniques were
not held and hands on skills practice were not
provided.
3. Contractual ANMs were not included in the
training load initially and no budget was
available with the district for training of LHVs.
4. The recall of the trainers regarding the training
and the Handbook was poor.
5. Training guidelines were not followed;
Handbooks not distributed and Immunization
film was not shown at some places
1. Training must be conducted at a well equipped
district training center.
2. Field Visit should be conducted during training.
3. Opportunity for hands-on skill practice must be
provided to all the participants.
4. Monitoring to ensure that the training
guidelines are followed, must be conducted
5. Training of more trainers in each district needs
to be considered.
6. Funds should be released from the state to
train the backlog of health workers.
Imm
un
iza
tio
n P
rog
ram
su
pp
ort
to H
Ws
1. Alt vaccine delivery system was functioning well.
2. Microplan with all components was not in place
3. Immunization waste disposal was very poor.
Concept of Safety pits not as per laid down GoI
guidelines
4. Poor supervision of RI sessions by MOs.
5. Solar cold chain equipment was lying
dysfunctional. Much equipment was lying in
irreparable condition.
6. Cold chain handlers lacked adequate knowledge.
7. Many of the ANMS were not paid their salaries
for months.
1. Prepare area maps and microplans.
2. Solar equipment can either be repaired or
modified and used on electricity.
3. Irreparable equipment to be condemned.
4. ILRs and DFs must be installed in the blocks on
priority.
5. Teach proper disposal of Immunization waste.
Supply twin buckets. Safety Pits must be
constructed as per laid down GoI guidelines.
6. Train cold chain handlers
Pe
rfo
rma
nce
of
HW
s
1. Knowledge of ANMs on RI was very good. ANMs
were motivated. ASHAs were giving good
support to HWs. Due beneficiaries list was found
at session sites. Despite inadequate supervision,
they were working well
2. Immunization waste disposal was not proper.
3. Recapping of needles was done at some places.
4. Four key messages were not given uniformly.
5. MCH register was very heavy and difficult to
carry.
6. Ticklers bags pockets size was smaller than card
size.
7. Inadequate recording and reporting at session
site.
8. Injection administration skills and screening for
contraindications need improvement.
1. Orientation on waste management needs to
be done.
2. ANMs to be encouraged to give 4 key
messages.
3. Registers need to be lighter and smaller.
4. New tickler bags with right size to be provided.
5. Proper training of all ANMs, LHVs, Cold chain
handlers and MOs is must at District level.
6. Hands on practice are required at District level
under the supervision of District trainers to
improve the injection administration skills and
tracking of beneficiaries.
44
Areas Major Observations Recommendations
Co
mm
un
ity
re
spo
nse
1. Aware about the immunization site. Minimal
resistance.
2. Majority of interviewed beneficiaries had
received vaccines as per schedule
3. AWW or Sahiya need to mobilize them for every
session.
4. Many are passive receivers of services. If the
card is lost or torn, they delay the next dose or
drop out altogether.
1. Four key messages by ANM on regular basis
can bring change.
2. IEC activity from district or state level
regarding RI will help.
3. MP
(Ratlam, Bhopal, Vidisha, Indore, Betul and Anuppur)
Areas Major Observations Recommendations
Qu
ali
ty o
f T
rain
ing
1. Contractual ANMs were not included in the
training load initially
2. State Level instructions were provided for
training of HW(F) only
3. Training institutions with proper residential
facility were not available in half of the districts.
4. Inadequate funds were made available
5. No field visits were conducted during the
training resulting in lack of hands on practice by
the HWs.
6. Inadequate no of trainers and mismatch
between recorded and actual no of trained
trainers.
1. Health Workers other than ANM must also be
trained in RI
2. Proper training facilities with residential
arrangements may be identified in all districts.
3. Timely provision of funds,
4. More District Level trainers must be trained so
as to continue training
5. District Health Educator must be a part of the
team to train on social issues related to RI.
6. Hands on practice should be regularly used.
7. All training material must be available at the
training facility before hand
Imm
un
iza
tio
n P
rog
ram
su
pp
ort
to
HW
s
1. Microplans and cold chain equipment were
available
2. Alternate Vaccine Delivery System was not
functional,
3. Plan for supervision and monitoring of RI
sessions was not prepared.
4. Supervision by medical officers / supervisors was
poor / ineffective
5. Poor cold chain maintenance and temperature
recording,
6. No dedicated cold chain handlers were available.
They were doing other accessory jobs in the
PHCs
7. Poor record keeping and waste disposal. Vaccine
Stock Registers were not properly maintained
8. Medical Officers were not oriented on recent
initiatives on RI
1. AVD to be made functional.
2. Microplanning must be done on priority,
buffer stocks to be kept to support RI activity
3. Train cold chain handlers, medical officers and
all other staff.
4. Need for close supervision and monitoring by
district level; avoid missing of sessions.
5. Supply hubcutters, red and black bags for
proper waste management.
6. Training of all categories of supervisors is
required on monitoring and supervision of
health functionaries involved in immunization
services.
45
Areas Major Observations Recommendations P
erf
orm
an
ce o
f H
Ws
1. Sessions being held as per RI Microplan. Health
staff and supportive staff were present.
2. Inadequate social mobilization.
3. Poor injection technique.
4. Poor communication with parents.
5. Poor recording and updating of counterfoils.
6. Basic facilities at session site (table, chairs) not
available.
1. Retraining of HWs by providing hands on
practice for improving aseptic Injection
technique, Communication skills and Social
Mobilization.
2. Provision of basic facilities at session site.
3. Improve tracking of beneficiaries by updating
of the counterfoils and use of tracking bags.
Co
mm
un
ity
re
spo
nse
1. Cooperative and receptive to advice.
2. Unaware about the services and poor knowledge
of benefits of immunization.
1. ASHA & AWW can be involved in educating
parents at session sites.
2. IEC materials to be displayed at session site.
46
4. Orissa
(Balasore, Gajapati, Nayagarh, Nuapada)
Areas Major Observations Recommendations
Qu
ali
ty o
f
Tra
inin
g
1. Training was residential.
2. Training was of good quality in Nayagarh and
Nuapada
3. Newly Recruited ANMs were not trained
4. Male health workers and health assistants were
not trained at some places
5. No budget available with the districts for training
1. Male health workers, health assistants and cold
chain handlers need to be trained.
2. Need to improve the hostel facilities at some
places.
3. Supervision and monitoring of the training
sessions must improve
Imm
un
iza
tio
n P
rog
ram
su
pp
ort
to
HW
s 1. Good Support staff available at the Block PHC.
Most of the HWs were trained. AVD was in
practice. Good record keeping and
documentation practiced at the PHC
2. Blocks were seen using stock pass books for
receiving and distributing vaccines
3. Maps were not displayed.
4. No Proper Disinfection & Disposal of used AD-
Syringes at the PHC. Safety Pits were
constructed but not used.
5. Block Level Supervision of the RI by medical
officers was poor. Sickness rate of DFs and ILRs
was high.
6. Vaccine Management in terms of buffer stock
needs to be addressed
1. Improve micro plans with maps.
2. Increase immunization sessions to two per
week.
3. Streamline immunization waste disposal
system.
4. Cold chain handlers’ training at the blocks is
needed.
5. Training of male Health Workers needs to be
done using the same module.
6. Supervision of RI sessions by Govt. officials
must improve. MOs need to supervise
Immunization sessions.
7. Vaccine management and Cold Chain issues
must be addressed at District level.
Pe
rfo
rma
nce
of
HW
s
1. Majority were knowledgeable and motivated.
2. Good record keeping in the Vaccine pass book &
proper vaccine indenting was practiced by
health Workers.
3. Good team work with Link workers like ASHA &
AWW.
4. Duration of RI-sessions held was short i.e. (From
9 am to 12 noon).
5. Only one RI day practiced in the State.
6. No proper waste disposal practiced.
7. Screening for contraindications needs to be
improved.
1. RI-session should be held from 9AM to 4 PM.
2. 2-RI days will help to conduct more sessions for
other hard to reach villages.
3. Refresher training is needed every alternate
year.
4. Improve biomedical waste disposal practices.
5. Ensure regular supply of immunization cards
and proper filling up of counterfoils during the
sessions.
Co
mm
un
ity
resp
on
se
1. Most of them were aware of antigens,
completed age appropriate Immunization as
per the RI cards available and were aware
about mobilization by link workers.
2. Card retention rate was less, some
beneficiaries were not aware about the next
due date of vaccination.
1. Outreach sessions should be planned more
frequently, at least twice a week.
2. Caregivers should be given the exact due date
for the next visit
47
5. Rajasthan
(Jaisalmer, Dholpur, Pali, Bikaner, Bhilwara)
Areas Major Observations Recommendations
Qu
ali
ty o
f T
rain
ing
1. Residential arrangements were available in 2
out of 5 districts.
2. Field visit was conducted in places where the
beneficiary load was not sufficient
3. Inadequate funds were reported for field visit of
the trainees for hands on practice.
4. Inadequate no. of trainers in some districts
5. Knowledge gap among trainers was observed.
1. Proper guidelines from the state to the
districts regarding budget, stay and food
arrangements should be sent.
2. Ensure hands on training for the HWs.
3. Build a pool of trainers in each district, sp.
from medical officers.
4. RI training must not be clubbed with any other
training.
Imm
un
iza
tio
n P
rog
ram
su
pp
ort
to
HW
s
1. Good infrastructure at block level. Most of ANMs
were trained. Tracking bags & Hub cutters were
provided to all ANMs, AVD is established by PHC
in decentralized manner, every PHC has cold
chain equipment.
2. ANM roster was available but No Maps, List of
villages was available but list of Dhani & Mazhra
was not available.
3. Block LHV/Cold chain handler/Data handler were
not trained. Vaccine Management needs
improvement
4. Poor immunization waste management. Open
safety pits. Sharps with other waste of session
sites were dumped in the safety pits.
5. Lack of supervision of the session sites by
Medical officers of the block
1. Proper microplanning required with maps
indicating distances from cold chain storage
point;
2. Improvement in record keeping especially
updating of logistics, issue registers, indent
forms, temperature log books;
3. Immunization waste management to be
streamlined.
4. Train the Cold Chain handlers, Block LHV and
Medical Officers on RI.
5. Ensure that vaccines are placed in zipper bags
and are delivered on the session day.
6. Supervision by district and block medical
officers must improve
48
Areas Major Observations Recommendations
Pe
rfo
rma
nce
of
HW
s
1. ANMs maintained good co-ordination with
anganwadi workers and ASHA for mobilizing
community, made list of due beneficiaries.
2. Immunization registers were available at most of
the sites
3. Knowledge of ANMs was good at some places
average at others
4. Technique of injection was not correct; DPT was
given on Hip and Measles at forearm at some
sites.
5. Functional hub cutter were not there at many
sites, even if present ANM was not cutting the
needle immediately after injection.
6. Recapping of needles was practiced by some
workers.
7. Record keeping was not proper; ANMs were
using daily dairy and not Immunization registers.
8. Tracking bags even if available, ANM was not
knowing how to use it, tally sheet was not used.
9. ANMs had no concept of waste management; all
were burning the syringes even if they were
provided with safety boxes.
10. Vaccine carrier was brought a day before in
Jaisalmer, resulting in melting of ice-packs.
11. 4 key IPC messages were not given.
1. Hands on practice needed as majority of
health workers did not have field visits during
the training.
2. Regular re-training to refresh and update the
knowledge.
3. More emphasis on immunization techniques,
biomedical waste management and tracking of
drop outs.
4. Provision of good quality functional
hubcutters, tracking bags, red & back bags etc.
5. All beneficiaries need to be screened for
contraindications and asked to wait for 15-30
minutes after vaccination.
6. Ensure that ANMs give 4 key IPC messages and
update the counterfoils after vaccination.
7. Supportive supervision by medical officers is
needed.
Co
mm
un
it
y r
esp
on
se 1. Community was aware and receptive
2. Not aware about importance of RI card, benefits
of immunization and possible AEFIs.
3. Some resistance among migratory population.
1. IEC and IPC in the community need to be
improved.
2. Training of ASHA to learn better community
mobilization especially in the resistant group.
49
6. UP
(Rampur, Moradabad, Lucknow, Saharanpur, Badaun, Sonbhadra, Ambedkarnagar, Basti, Fatehpur,
Jaunpur, Mahoba)
Areas Major Observations Recommendations
Qu
ali
ty o
f T
rain
ing
1. Training centers were available in 80% of the
districts but stay arrangements were made only
by 40% of the districts.
2. Less number of ToT trained trainers were
available in many of the districts.
3. Batch size was found higher at some places
4. No hands on skill practice were provided at
some places.
5. Only ANMs and LHVs were trained.
6. Funds were not provided to complete the
training.
7. Frequent change of DIOs and transfer of TOT
trained trainers at some places
1. Strengthen the training facilities including stay
and transport in each district.
2. Provide opportunity for hands on practice by
taking the participants to 3-4 different session
sites.
3. Train the backlog of HWs and other categories
as HW male, HA male, cold chain and data
handlers at PHC and District level.
4. Train more trainers for the districts with
shortage.
5. Provide sufficient funds for training.
6. DIO should be made responsible for only
immunization and not for other programmes
7. Programme Managers at all levels must be
involved in the training sessions
8. Monitoring of Training sessions by District Level
Officers and partner agencies must be done
Imm
un
iza
tio
n P
rog
ram
su
pp
ort
to
HW
s
1. Good Infrastructure including cold chain
equipment available in all the blocks. Alternate
vaccine delivery system is functioning in some
districts. Vaccine supply is good.
2. Map of the area with sub-centers not available.
3. Alternate vaccine delivery not practiced in all the
districts.
4. Cold chain equipment maintenance is poor.
5. Shortage of Immunization cards, functional hub-
cutters, red and black bags not available.
6. Poor waste management: shallow and open pits
used for burning and burying the immunization
waste.
7. No supervision is practiced.
8. No AEFI or VPD were reported in last 3 months
9. Huge no. of non-functional cold chain equipment
were occupying space at the blocks.
1. Train Medical officers in immunization and
urgently train the IO and ICC with HWs.
2. Map of the area showing sub-centers, distance
from ILR points and alternate vaccine delivery
plan need to be displayed at each PHC.
3. Provide mobility support to medical officers
for the field visit and supervision of RI.
4. Train the staff in record maintenance, cold
chain maintenance and safe waste disposal
during meetings at the block.
5. Improve waste disposal by supplying
hubcutters, using disinfection procedures and
monitoring
6. Cold Chain Management and supply and stock
management needs improvement. Recording
of temperature and log books needs to be
streamlined
7. Supply Immunization Cards and voltage
stabilizer.
50
Areas Major Observations Recommendations P
erf
orm
an
ce o
f H
Ws
1. HWs have improved knowledge and techniques
of vaccination after training, conducting sessions
as per micro-plan.
2. Due list of beneficiaries was not available at the
session site.
3. Some ANMs still found practicing unsafe
injection practices as recapping needles.
4. Key IPC messages were not given.
5. Poor documentation of vaccination and updating
of counterfoils.
6. Poor social mobilization.
7. Improper waste disposal, functional hub cutters,
red and black bags were not available.
8. Screening for contraindications and asking
beneficiaries to wait for 15-30 minutes needs to
be improved.
9. Sessions were being held at the same site in a
big village.
1. Need for hands on training and practice of
injection administration techniques.
2. Regular training and retraining in RI every
year.
3. Proper microplanning is required with map so
that no area is missed.
4. Supervision and OJT by MOs for use of tracking
bags, IPC skills.
5. Poster on key messages in Hindi to be
displayed at the session site.
6. Provide logistics of PCM, Hubcutters, red bags,
tally sheets etc.
7. Need to update immunization register by
including information from the registers of
AWW and ASHA as well as New born tracking
booklets of SIAs.
8. Preparing due lists, updating counterfoils and
using tracking bags should be encouraged.
9. Different session sites can be planned in big
villages.
Co
mm
un
ity
re
spo
nse
1. Good acceptance and awareness in the
community
2. Majority did not have immunization cards.
3. Not aware about the next due date.
4. Dependent on the ASHA and AWW to take them
to the site.
5. Poor knowledge about AEFIs and their
management.
1. Good Quality IPC by health Workers, AWWs
and ASHAs will motivate mothers to come for
RI, at the Session sites.
2. To utilize ASHA effectively for tracking of new
born and drop-outs.
51
Uttarakhand
(Tehri, Champawat)
Areas Major Observations Recommendations
Qu
ali
ty o
f T
rain
ing
1. Newly Recruited and contractual ANMs were
not included in the original training plan
2. Training of HW (M) was not planned for
training, as HW (M) is attached to Panchayat
Department
3. No Training facility in the districts - training
done at CHC and PHC.
4. Improper stay arrangements at the block level.
5. Hands on training were not conducted.
6. Only 2 trainers were trained.
7. Gaps were found in trainer's knowledge on
cold chain, micro-planning, waste disposal etc.
8. Inadequate and unorganized records of
training
9. Pharmacists also need to be trained in RI
1. Training center with all required training
facilities including stay arrangements needs to
be established in the district.
2. Refresher for half a day practical session at CHC
for all ANMs in batches can be conducted.
3. POL/mobility support to district trainers to go
to remote blocks be given.
4. Proper maintenance of training records by
responsible persons is needed.
5. Cold Chain Handler basic training needs to be
done.
Imm
un
iza
tio
n P
rog
ram
su
pp
ort
to
HW
s
1. Good infrastructure available, good electricity
supply and cold chain equipment in good
condition
2. Vacant sub-centers and male HWs were
attached to Panchayat dept. with minimal
involvement in health related activities.
3. Map of the area with sub-centers not
available. No Microplan only VHND roster was
available.
4. No alternate vaccine delivery practiced,
vaccine being given to ANMs one or two days
prior to immunization day.
5. No proper method for waste disposal-no
bleaching solution, open disposal pit-burning
and burying done.
6. No AEFI or VPD reported in last 3 months.
7. No dedicated and trained Cold Chain Handler
at Block
1. Proper utilization of male HW, pharmacist,
staff nurse after training.
2. Vaccine flow from District level needs to be
addressed. Courier system can be used for
vaccine delivery.
3. Preparing Microplans on priority. Display map
of the area showing sub-centers, distance from
ILR points and alternate vaccine delivery plan.
The missed villages can be covered using 3
Wednesdays.
4. Train cold chain handlers and data handlers.
5. Proper waste disposal as per CPCB guidelines.
6. Train Medical Officers on RI
52
Areas Major Observations Recommendations
Pe
rfo
rma
nce
of
HW
s
1. Good communication with ASHA/AWW,
Motivated health staff, Regular visits to
VHNDs, Good supply of logistics to HWs,
conducting sessions on all Saturdays in AWCs.
2. Due list of beneficiaries and counterfoils were
not available.
3. Injection technique was faulty in majority of
sessions.
4. Key IPC messages not given.
5. Poor documentation of vaccination.
6. No hub-cutters, no plastic bags available
7. Screening for contraindications was a weak
area .
1. Regular training of HWs to practice the
injection administration skills is needed.
2. Supervision and OJT by MOs.
3. Tracking bags were distributed; their use
should be explained and ensured.
4. Poster on key messages in Hindi to be
displayed at the session site.
Co
mm
un
ity
resp
on
se
1. Community awareness about place of session
(sub center) on first Wednesday was high.
2. Demand generation was good, almost no
resistance.
3. Accessibility is an issue as population is
scattered, terrain is difficult and sessions are
not held in all the villages.
1. Sessions can be held once in 3 months in very
difficult to reach and uncovered villages.
2. Need to keep in touch with AWW to know the
date of vaccination and to keep the
immunization cards safe
53
Annex-2: Suggested guidelines for immunization training of health workers
Duration of training 2 working days
No. of trainees per batch 12-15
Venue District Hospital and ANM Training Center (ANMTC)/ First Referral Unit/ Community
Health Center (CHC)
Trainers District Immunization Officer /ANMTC trainer / Pediatrician/ CHC Medical Officer
No. of trainers 1 facilitator for each group of 4-5 trainees
Methodology Group discussions, Exercises, Demonstration and Return Demonstration, Hands-on-
practice, Role play, Field Visit, Film show
Annex-3: Tentative Programme for Immunization Training of Health Workers
Day-I
09.00 – 09.30 Registration
09.30 – 10.15 Inauguration, Expectations of the participants and Pre testing
10.15-10.45 Introduction and formation of groups of 4-5 participants with one
facilitator each
Unit -1
10.45 – 11.30 Briefing on VPDs and Vaccines followed by film. Unit-2
11.30 – 11.45 Tea
11.45 -12.30 Quiz on filling of National Immunization Schedule in groups Unit -3
12.30 – 13.30 Lunch
13.30– 15.30 Discussion on microplan for immunization
Preparation of microplan (exercise).
Discussion on session site checklist.
Conducting immunization session and educating parents (role
play)
Unit -6
15.30 – 15.45 Tea
15.45 – 17.15 Briefing on cold chain and injection safety equipment and Records
and Reports
Units- 4, 5 and 8
Day-II
08.00- 13.00 Field visit – Each group to visit different PHC/CHC/Distt Hospital to
observe cold chain system and practice giving safe injections and
dispose immunization waste safely as per the guidelines using hub
cutter and Demonstration on records and reports
13.00 – 14.00 Lunch
14.00 – 15.00 Discussions on observations made during the field visit and
Each group to present
15.00 –15.30 Discussion on AEFI and how to prevent it: Unit-7
15.30 – 15.45 Tea
15.45- 16.15 Discussion on surveillance of VPDs: Unit-10
16.15 -16.45 Discussion on how to involve community for increasing coverage and
reducing dropout
Unit-9
16.45-17.15 Open discussion, Post test and conclusion.
54
Annex-4: Detailed day-wise Tasks for each team
No State Session Day 1st day 2nd day 3rd day 4th day 5th day
1 Bihar Wednesday,
Friday
Tuesday
District visit
Visit to 4
session
sites
Interviews
at PHCs
(both)
Visit to 4
session
sites
-------------
2 Jharkhand Thursday,
Saturday
Wednesday
District visit
Visit to 4
session
sites
Interviews
at PHCs
(both)
Visit to 4
session
sites
-------------
3 Madhya
Pradesh
Tuesday,
Friday
Monday
District
interviews
Visit to 4
session
sites
Interviews
at PHC -1
Interviews
at PHC-2
Visit to 4
session sites
4 Orissa Wednesday Tuesday visit
to
District and 2
PHCs
Visit to 8
session
sites
------------ ---------- --------------
5 Rajasthan Thursday,
Monday
Wednesday
District visit
Visit to 4
session
sites
Interviews
at PHC-1
Interviews
at PHC-2
Monday –visit
to 4 Session
sites
6 Uttar
Pradesh
Wednesday,
Saturday
Tuesday
District visit
Visit to 4
session
sites
Interviews
at PHC-1
Interviews
at PHC-2
Visit to 4
session sites
7 Uttarakhand Wednesday,
Saturday
Tuesday
District visit
Visit to 4
session
sites
Interviews
at PHC-1
Interviews
at PHC-2
Visit to 4
session sites
Location Tasks
Day 1
(All
states)
District
HQ
���� Meet the CMO / CS. Explain the purpose and plan of the visit
���� Meet the DIO and district trainers. Arrange for one vehicle for each
day and two vehicles for the two session days.
���� Visit District training center and collect information in study tool-1
���� Collect the list of health workers trained from the selected blocks
���� Select two Blocks randomly (with trained health workers available) -
one within15 kms and other more than 15 kms from district HQ;
���� Collect the Monthly Progress Report for last 3 months for the
selected blocks
Selected
Block – 1
(and block
2 for
Orissa)
���� Meet the MO. Explain the purpose and plan of the visit
���� Take copy of the micro-plan of the PHC, Map of the block and list of
trained health workers.
���� Divide the Block into 4 zones and select one trained health worker
from each zone randomly (total four health workers) for observation
on session day. Exclude the HWs posted at the PHC HQ.
���� Request MO for 1 person to accompany each team member to the
session site.
���� Note the mobile number of the medical officer before leaving for the
session site
���� If possible try to fill study tools 2 and 3.
55
Day 2 (All states)
4 Session
sites of
Block 1
(and block
2 for
Orissa)
���� Each one of you will visit two health workers (at different session
sites) and explain the purpose and plan of your visit
���� Collect information in study tool-4 by talking to health worker and
observation; study tool-5 by observing the HW providing services to 2
beneficiaries and exit interview of two care givers and study tool-6 by
visiting 4 houses with 0-2 yrs children and talking to their caregivers.
Day 3 (UP,
Uttarakhand,
MP and
Rajasthan)
Selected
Block – 1
���� Collect information in study tool-2 and 3
���� Enter the data into the Data entry tool in excel format as provided.
Day 3 (Bihar,
Jharkhand)
Selected
Blocks – 1
and 2
���� Collect information in study tool-2 and 3
���� Select four trained health workers for observation on session day
Day 4 (UP,
Uttarakhand,
MP and
Rajasthan)
Selected
Block – 2
���� Collect information in study tool-2 and 3
���� Select four trained health workers for observation on session day
Day 4 (Bihar,
Jharkhand)
4 Session
sites of
Block 2
���� Same as given above against day2 for all states.
Day 5 (UP,
Uttarakhand,
MP and
Rajasthan)
4 Session
sites of
Block 2
���� Same as given above against day2 for all states.
56
Annex-5: Study Tools 1 to 6
Study Tool No. 1
Tool to collect information from District Immunization Officer/ District Training
Coordinator/Trainer
A. General Information
1 State (name ):
2 District (name ):
3 Date of interview (date on which
this format is filled)
4 Name/s of Investigators 1. 2.
5 Name of the District
Immunization Officer (DIO)
6 Name and designation of the
interviewee/s
1.
2.
B. Information regarding training of health workers in the district (ask specifically for two days
training with Immunization Handbook for Health Workers)
1. Routine Immunization Training status of health workers in the District (write the numbers)
Category Staff in position
(number)
Staff Received
training (number)
Reasons if all not trained
ANM(HW-F)
LHV (HA-F)
HW (M)
HA (M)
Any other category (specify)
Total
(Tick the responses where required)
2 No. of training courses (batches) conducted
3 When was last training batch conducted
���� with in 1 yr ���� 1-2 yrs back ���� >2 yrs back
4 No. of TOT trained trainers available in the district
(trained as trainers at state / divisional level)
5 No. of Trainers involved in each HW training course on
both days (check report if available)
���� 2-3 ���� 4 ���� >4
6 Training was residential (trainees stayed overnight) ���� Yes ���� No
7 Field visit organized to DH/CHC/PHC for the trainees to
practice giving safe injections (ask where?) � Yes � No
8 Training and other materials given to all participants (in
local language) (First ask open ended question. Prompt
only if unable to answer)
� Immunization Handbook
� Handouts from Facilitators Guide
� Certificates
���� Other (specify) ___________
9 Pre/post test done. If yes, try to verify (ask for few filled
in Handout no. 1)
� Yes � No
10 Feedback received from trainees at the end of training
(ask for a few filled in Handout no. 8)
� Yes � No
57
C. Ask the following questions to assess the knowledge and skills of the trainers and
grade the responses Questions Expected Answers Rating
1 How would you
describe and
demonstrate
“conditioning of ice-
packs” to HWs
1. Remove the ice packs from the freezer and
keep them outside till you hear the sound of
water inside the icepack when shaken next to
the ear.
2. The icepacks need to “sweat,” i.e. some
condensation or droplets of water on them.
3. The time taken for conditioning ice- packs is
not fixed; it varies depending on the outside
temperature.
���� Excellent
(if all three points are mentioned)
���� Good
(If any two points mentioned)
���� Average
(if any one point mentioned)
���� No Response
(if no points mentioned)
2 Demonstrate use of AD
syringe for giving DPT
injection to an infant
1. Opens the package from the plunger side and
removes the syringe by holding the barrel.
2. Site of injection – Antero-lateral aspect of the
thigh (mid-outer thigh).
3. Angle of injection - Hold the syringe like a pen
in the right hand and push the needle straight
down at 90 deg. through the skin. Penetrate
deep into the muscle.
���� Excellent
(if all three points are mentioned)
���� Good
(If any two points mentioned)
���� Average
(if any one point mentioned)
���� No Response
(if no points mentioned)
3 Demonstrate use of
Hub-cutter and safe
waste disposal
1. Cut plastic hub of AD syringe and not the
metal part of needle immediately after
administering the injection at the
immunization site using the Hub cutter
2. Treat the collected material in an autoclave
or boil such waste in water for at least 10
minutes or chemical treatment (using at least
1% solution of sodium hypochlorite for 30
minutes).
3. Dispose the disinfected waste as follows:
1. Dispose the needles and broken vials in a
safety pit/tank
2. Send the syringes and unbroken vials for
recycling or landfill.
���� Excellent
(if all three points are mentioned)
���� Good
(If any two points mentioned)
���� Average
(if any one point mentioned)
���� No Response
(if no points mentioned)
4 How did you train HWs
on management of
AEFIs
1. Discussed with participants any AEFIs they
may have come across
2. Read definition and types of AEFI from the
Handbook.
3. Discussed ways to minimize AEFIs in their
areas
4. Discussed what to do if AEFI occurs.
���� Excellent
(if all four points are mentioned)
���� Good
(If any three points mentioned)
���� Average
(if any one or two point
mentioned)
���� No Response
(if no points mentioned)
5 How did you train HWs
on “Increasing
1. Discussed possible reasons for the left-outs,
drop-outs and fully immunized with trainees
���� Excellent
(if all three points are mentioned)
11 Mention any specific action taken to improve training
based on feedback.
58
Immunization
Coverage” and tracking
of drop outs?
by dividing them in 3 groups, each with one
facilitator
2. Discussed possible ways of addressing drop-
outs and left outs based on “Actions to be
taken” mentioned in the Handbook and their
field situations.
3. Showed film on Improving Immunization
Coverage
���� Good
(If any two points mentioned)
���� Average
(if any one point mentioned)
���� No Response
(if no points mentioned)
Give overall assessment of the trainers based on responses received above, by giving scores out of 5
Count all the ratings given
for the above 5 questions
(excellent, good and
average) and then give
scores out of 5 as detailed.
5 Points: If at least 3 excellent OR 5 good
4 points: If at least 2 excellent OR 4 good
3 points: If at least 1 excellent OR 3 good
2 points: If no excellent point, but 2 good
1 point: If 4 or more responses are average
���� 5
���� 4
���� 3
���� 2
���� 1
D. Information regarding problems faced and suggestions:
1 Problems faced in Immunization Training (Ask
open-ended questions)
2 Suggestions for future training courses related to:
Course Contents
Training methodology
Class rooms and transport facilities at the
training center
No. of Trainers
Flow of Funds as per Training norms
Any other support required
3 Suggestions for changes in the Immunization Handbook:
Areas to be added
Areas to be deleted
Areas to be modified
E. Observe the facilities at the training centre (Tick appropriate response only if available at
the training center by visiting the venue of training)
59
���� Classroom
���� Black /white board
���� Flip charts/marker pens
���� LCD/VCD player
���� Hostel-rooms
���� Mess
���� Water facilities
���� Electricity
���� Transport (own/hiring)
���� No training facility
available
F. Major observations and suggestions of the Study Team:(Write the major gaps identified and observed )
-------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------
• Select two Blocks randomly (with trained health workers available) - one within15 kms and other
more than 15 kms from district HQ;
• Collect the list of health workers trained from the selected blocks and the MPRs for last 3 months
from the selected blocks.
Study Tool No. 2
Tool to collect information from Block /PHC Medical officer A. General Information
1 State (name ):
2 District (name ):
3 Block/PHC (Name of Block or
PHC being assessed):
3 Date of interview (date on which
this format is filled)
4 Name/s of Investigators 1. 2.
5 Name and designation of the
Medical officer
1.
2.
B. Routine Immunization Training status of health workers in the Block/PHC
Category Staff in position
(number)
Staff Received
training (number)
Reasons if all not trained
ANM(HW-F)
LHV (HA-F)
HW (M)
HA (M)
Any other category (specify)
C. Routine Immunization services at the PHC (Talk with the medical officer and observe. Tick the appropriate
60
response)
1. Is RI Micro-plan with the following components available at the PHC? (Ask to see the micro plan of the block
and observe the following)
a) Map of catchment area including all sub-centers and distances from
vaccine storage point
���� Yes ���� No
b) Estimation of beneficiaries and logistics for current year ���� Yes ���� No
c) Roster of health workers ���� Yes ���� No
d) Alternate vaccine delivery plan to supply the vaccines and logistics to
session sites?
���� Yes ���� No
If not, mention the reason (by asking the interviewee)
2. Is Coverage monitoring chart/drop out chart displayed at the PHC ���� Yes ���� No
3. Any stock-outs or shortage (vaccines, syringes etc.) reported in last 3
months? (check records – vaccine stock register)
���� Yes ���� No
If yes, specify
4. How the disinfection and disposal of used syringes and needles is carried
out? (Ask the medical officer and look for the waste disposal pit)
5. Mention the methods used for disposal of disinfected sharps (cut needles,
broken vials & ampoules)? (Observe for any used syringes / vaccine vials lying
scattered in PHC area)
���� Disposal pit
���� Other means specify
���� No proper method
6. How many supervisory visits were undertaken to SC/Session site during last 3 months (write total number):
By Medical Officer
By other supervisors of HWs
7. Which records are available at the PHC to support the supervisory visits
���� movement registers
���� log book
����supervisory checklists/reports
���� No records
8. Mention 1-2 areas in which you have noted change in the performance of
HWs after training
(Ask open-ended question initially. If unable to get the response, then prompt
for areas such as micro planning, injection technique, recording and
reporting, tracking of drop-outs, waste disposal, community mobilization etc.
Note responses)
D. Availability of equipment and supplies at the Block/PHC (Ask medical officer / cold chain handler / data
handler and try to observe)
Equipment and Supplies Number
available
Numbers
functional
Remarks if not functional
1 Deep Freezers
2 Ice-lined Refrigerators (ILRs)
3 Voltage Stabilizers
4 Cold Boxes
5 Vaccine Carriers
61
6 Icepacks
7 Thermometers
Tick only if the following is available at the block
���� Vaccine and Logistics indent forms
���� Supply vouchers
���� Issue register / record
���� ADS 0.1 ml
���� ADS 0.5 ml
���� Disposable syringes
���� Hub cutters
���� Bleaching solution
���� Waste Disposal pit
���� Immunization cards
���� Tracking bags
���� Immunization register
E. Cold chain and logistics support to the health workers at the PHC
1. Are temperature log books maintained correctly (temperature recorded
twice daily; signatures of cold chain handler daily and MO weekly)
���� Yes ���� No
2. Is stock register maintained correctly (1. Check for entries, 2. Check stock
entry of any 1 vaccine and cross-check with physical stock)
���� Yes ���� No
3. Is VVM in usable stages (Inner square is lighter than the outer circle) –
Refer to figure at end of Tool 2
���� Yes ���� No
4. Are ice-packs conditioned correctly (Ask cold chain handler to
demonstrate)
���� Yes ���� No
5. Additional Comments:
-------------------------------------------------------------------------------------------------------------------------------------------------------
F. Major observations and suggestions of the study team:
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------
����
Inner square lighter than the outer circle If the expiry date has not been passed USE the vaccine
At a later time, inner square still lighter than the outer circle If the expiry date has not been passed USE the vaccine
Discard point: Inner square matches colour of the outer circle DO NOT use the vaccine Inform your supervisor
Beyond Discard point: Inner square darker than outer circle DO NOT use the vaccine
����
����
����
Vaccine Vial Monitors showing different stages
62
Study Tool No. 3
Checklist for Record Study (Look for Monthly Progress Reports for last 3 months) Name of Block or PHC: …………………………..
• Take copy of the micro-plan of the PHC, Map of the block and list of trained
health workers.
• Divide the Block into 4 zones and select one trained health worker from each
zone randomly (total four health workers) for observation on session day.
• Exclude the HWs posted at the PHC HQ.
• Request MO for 1 person to accompany each team member to the session
site.
• Note the mobile number of the medical officer before leaving for the session
site
Note down the following information for next session day: (Please identify few additional ANMs around the
randomly selected session sites where we can find a trained HW, in case, the HW in the chosen site does not
turn up)
Name of HW selected Name of Sub-center Village Session Site
More than 80% of planned sessions held ���� Yes ���� No
Any AEFI reported in last 3 calendar months ���� Yes ���� No
Any VPD reported in last 3 calendar months ���� Yes ���� No
63
Study Tool No. 4
Interview Schedule for Health Worker who received Immunization training A. General Information
1 State (Name): 2 District (Name):
3 Block/PHC (Name): 4 Sub-center(Name):
5 Name of the investigator: 6 Date of visit:
7 Name of Health Worker:
8 Designation of Health Worker ���� ANM/Health Worker Female
���� LHV/ Health Assistant Female
���� Male Worker/MPW/Health Assistant Male
���� Other (specify) ___________
9 Total years in service ���� <2 yrs ���� 2 – 5 yrs ���� 5 – 10 yrs ���� >10 yrs
10 No. of health workers posted at the sub-center ���� 1 ���� 2 ���� 3
11 Is the HW staying at the sub-center ���� Yes ���� No ���� Accommodation Not Available
12 Total Population covered by the health worker
13 All the villages / areas assigned to the health
worker, are covered by her (check micro plan and
map for any missed areas)
���� Yes ���� No
14 Has any Supervisor visited sessions in HWs area in last 3 months? (Try to check for signatures of supervisors)
Medical Officer ���� Yes ���� No
Other supervisors ���� Yes ���� No
B. About the Training course
1 When was the training attended by you (no. of months/ yrs
passed)
���� < 6 mths
���� 6-12 mths
���� 1-2 yrs
���� > 2yrs
2 Duration of training course (no. of days) ���� 1 day
���� 2 days
���� 3 days
���� > 3 days
3 Name of the training center (where trained)
4 Any other immunization training received in last 3 years ���� Yes ���� No
If yes, specify
5 How many trainers were available on both days ���� 2 ���� 3 ���� 4 ���� >4
6 Was film on immunization shown during the training? ���� Yes ���� No
7 Was a field visit organized to DH/CHC/PHC for the trainees
to practice giving safe injections
���� Yes ���� No
8
If yes, how many injections did you practice for each vaccine? ���� BCG ________ � None
���� DPT ________
���� Measles________
9 Did you receive Certificate at the end of training? ���� Yes ���� No
10
Did you receive a copy of the Immunization Handbook
in Hindi during the training workshop
���� Yes ���� No
11 Did you refer the Immunization handbook after training? ���� Yes ���� No
12 Where is the Immunization handbook at present? ���� SC ���� Session ���� Home ���� Lost
13
Give two examples of improvement in your immunization
practices after training (Prompt only if unable to respond)
64
14
Mention any new initiatives/activities conducted to improve
community involvement after training
15
Which Sessions during training you liked the best
16
Which Sessions during training you liked the least
17
What are your suggestions to improve the Immunization
Handbook?
18
Any comments on boarding and lodging facilities at the training
center?
19 Duration of training (tick response) ���� Adequate ���� less ���� more
20 Did you face any difficulties during training including field visit? ���� Yes ���� No
If yes, mention them
21 Do you need further training in immunization? ���� Yes ���� No
If yes, in which areas?
22 What should be the methodology of such trainings?
(Ask open-ended questions and tick on appropriate response)
���� Role plays
���� lecture
���� field visits
���� reading from handbook
���� films
���� group work
���� Others
23
Give suggestions for improving future training
C. Assessing Knowledge
(Ask the following open ended questions and write the responses given, then tick whether correct)
1) If a child comes for vaccination for the first time at 16 months of age, what should be given
• ……………………………
• ……………………………
• ……………………………
• …………………………….
(If the answer is DPT 1 + OPV 1 + Measles + Vitamin A, then tick YES, otherwise NO) Yes No
5) A child received BCG, DPT1 and OPV1 at the age of 1 and half months. Then comes again after a gap of 6 months.
Which vaccines will you give?
a. ……………………………
b. ……………………………
c. ……………………………
d. …………………………….
(If the answer is DPT 2 AND OPV 2, then tick YES, otherwise NO) Yes No
6) What is the dose of Vit A solution for a child above 1yr of age?
65
• …………………………….
(If the answer is 2 ml (2 lakh IU), then tick YES, otherwise NO) Yes No
7) How can you track drop out children
• ………………………………..
• ………………………………..
• ………………………………..
(If the answer includes counterfoil of immunization card + tracking bag + immunization register, then tick YES,
otherwise NO) Yes No
8) What will you do if a child comes to you with mild fever, pain and swelling at the site of injection?
• ……………………………………
(If the answer includes give Paracetamol + ask care giver to apply cold cloth at injection site + reassure, then tick
YES, otherwise NO)
Yes No
9) What is the route of administration and injection sites for the following vaccines:
a. BCG: ___________________________ (Correct answer – intradermal, left upper arm) Yes No
b. DPT ___________________________ (Correct answer – intramuscular, outer mid-thigh) Yes No
c. Measles _________________________ (Correct answer – subcutaneous, right upper arm) Yes No
D. About the Session Site (Note your observations)
1 Session Site ���� Anganwadi Center ����Sub Center
���� Other
2 Is the session site as per RI micro plan? ���� Yes ���� No
3 Due list of beneficiaries is available for this day? ���� Yes ���� No
4 Has the HW involved ASHA/ AWW/ any other mobilizer for contacting
beneficiaries to come to the session
���� Yes ���� No
5 How and when the vaccines reached the session site
6 Is vaccine carrier with four ice-packs available ���� Yes ���� No
7 Are the conditioned icepacks available in the vaccine carrier? ���� Yes ���� No
8 Is VVM in correct stage (all vaccines) ���� Yes ���� No
9 Are reconstituted vials kept in shade on the ice-pack ���� Yes ���� No ���� N/A
10 Is time of reconstitution written on BCG and Measles vials ���� Yes ���� No ���� N/A
11 Look for availability of vaccines and logistics (If yes, then Tick whichever appropriate)
���� BCG ���� Measles ���� DT ���� Functional hub cutter
���� BCG Diluent ���� Measles Diluent ���� Vitamin A ���� Tracking Bag
���� tOPV ���� JE ���� Blank Immunization Cards ���� 0.1 ml AD Syringes
���� DPT ���� JE Diluent ���� Red Disposal Bags ���� 0.5 ml AD Syringes
���� HepB ���� TT ���� Black Disposal Bags ���� Disposable Syringes
66
Study Tool No. 5
Checklist for observing the skills of Health Worker in conducting immunization
session
Name of Health Worker: ……………………………….. During the immunization session, try to observe at least 2 beneficiaries being vaccinated by the HW
Attention: Observe the following interactions of health workers with beneficiaries / caregivers. Tick whether they
perform the procedure and if so, tick whether you judge the performance to be competent or needs to be improved.
Observations during vaccination session
1st
client 2nd
client Assessment
The health care provider, Not
observ
ed
Done Not done Not
observed Done
Not
done
Not
observe
d
Competen
t
Needs
to
improve
• Welcomes beneficieries
• Verifies beneficieries records for vaccination
• Explains what vaccine(s) will be given and the
dısease(s) prevented
• Screens for contra-indications
• Checks that it is the correct date for the vaccination
• Uses AD syringe to give vaccination
• Uses new disposable syringe for each reconstitution
of the vaccines.
• Maintains aseptic technique throughout
• Injects vaccine using the correct route for the
vaccine (intramuscular / sub-cutaneous /
intradermal)
• Allows dose to self-disperse instead of massaging
• Explains potential adverse events following
immunization (fever / pain / swelling)
• HW discusses with beneficieries /parents about
next visit
• Documents each vaccination correctly and
completely (In the card and register)
• Updates counterfoil of the beneficiary after
vaccination
• Cuts each AD and Disposable syringe with hub
cutter immediately after use?
• Used syringes (after cuting the needle) are kept in
red bag for sending back to PHC?
• Asks the beneficiaries to wait for 15 – 30 mins after
vaccination
Talk to 2 care givers (tick all that apply) Mother 1 Mother 2 Competent Needs to
improve
Look at the immunization card and check if
the immunization schedule has been followed
correctly
Yes No Yes No
67
Specify the areas which need improvement:
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Study Tool No. 6
Checklist for House to house visit to assess knowledge of care givers (Select four households with children in the age group of 0 to 2 years and visit them to collect
the following information from the care givers)
Name of the Health Worker: ………………………………..
SN Questions House-1 House-2 House-3 House-4
1 Aware about the place where
immunization session is held
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
2 Knows about the site of vaccination
of her child (Right or Left Arm, Mid-
thigh)
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
3. Knows about minor adverse events
following immunization (fever, pain,
swelling)
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
4 Knows what to do in case minor
adverse events following
immunization occur (Report to the
health worker, in case these events
do not subside)
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
5. Child received age appropriate
vaccines (check RI card if available)
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
6 Whether she knows when to go for
the next due vaccine for her child
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
���� Yes
���� No
7 Whether she was reminded for ���� Yes ���� Yes ���� Yes ���� Yes
Select four households with children in the age group of 0 to 2 years and visit them to collect information
in Study Tool-6.
68
vaccination prior to vaccination day
(by ASHA / AWW / social mobilizer)
���� No ���� No ���� No ���� No
Summary of Observations and Suggestions by the Team after completion of all
the study tools
Name of the District---------------------------
Level Strengths / positive
observations Problems / issues Recommendations
District
Block
Heath
Worker
Beneficiaries
/ Caregivers
69
Annex-6: List of Study Team Members
Organization Study team members
NIHFW Dr. Utsuk Dutta, Dr. J. K. Das, Dr. Sanjay Gupta, Dr. Vivek Adhish, Dr. Gyan
Singh, Dr. Bindoo Sharma, Dr. Vandana Bhatnagar, Ms. Renuka Patnaik, Dr.
Santosh Kumar, Dr. Abhiman Chauhan, Dr. Rupesh Parpe, Dr. Gaurav
Chaudhary, Dr. Rishi Bharti, Dr. Chitra, Dr. Sanjay Sinha, Dr. Aditya
Chaudhary, Dr. Geetanjali, Dr. Ashoo, Dr. Sunil, Dr. Sanjay Mattoo, Dr.
Dheeraj, Dr. Nishant, Dr. Hema Gogia, Dr. Sonia, Dr. Priyanka, Dr. Indu, Dr.
Subhash, Dr. Madhu, Dr. Kumud, Dr. Balbir Dewan, Dr. Anupama Arya, Dr.
Devender Megha
WHO-NPSP Dr. Balwinder Singh, Dr. Renu Paruthi, Dr. P. K. Roy, Dr. B.P.Subramanya, Dr.
Chandrakant Lahariya, Dr. Siddhartha Datta, Dr. S. Routray, Dr. Ashfaq Bhat,
Dr. Leena Mane, Dr. Mukesh Bachawat, Dr. Vipin Kumar, Dr. Kanupriya
Singhal, Dr. Suresh Dalpath
WHO – SEARO Dr. Nihal Abeysinghe, Dr. Jayantha Liyanage
WHO-HQ Ms. Jhilmil Bahl
UNICEF Dr. Satish Gupta
IMMbasics Dr. Neeraj Aggarwal
NIHFW/UNICEF Dr. P. Deepak
NIHFW/USAID Dr. Sudhir Maknikar
NIHFW/UNFPA Dr. Vertika Kishore
State
Government
Dr. Sadhna, Dr. Sushma Datta
SIHFW Dr. K. K. Das, Dr. R. K. Batra
Medical college Dr. Ashok Mishra, Dr. Y. D. Badgayan, Dr. Salil Sakale, Dr. Sanjay Dixit, Dr.
Minoti Rath, Dr. S.B. Bansal, Dr. Sonali Kar