An Evaluation Of Expanded Programme On Immunization And The Factors Influencing Community Participation (Case Study Of Elimina Sub-District)

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An Evaluation Of Expanded Programme On Immunization And The Factors Influencing Community Participation (Case Study Of Elimina Sub-District)


The purpose of this study was to find out the factors influencing community participation in Expanded Programme for Immunization (EPI) in Elmina sub-District of Ghana. In this survey data were collected from 15 purposively selected community health nurses and 279 conveniently chosen community members. Five research questions and two hypotheses guided the study. Two questionnaires; health worker questionnaire and community members, were utilized for data collection. The results indicated that community members participated minimally in EPI programmes. Using ANOVA, the results revealed that there was a significant difference in members’ participating in EPI according to educational status; F (3, 275) = 3.3, p < .05. Scheffe follow up test indicated that community members without formal education were better in participation in EPI programme (M = 4.87; SD = 6.27) than those with tertiary education (M = 1.60; SD = 3.66). In addition, regression analyses indicated that community-based factors (beta = -6.23, t = -3.28, p < .05) and health worker factors (= -6.29, t = – 4.02, p < .05.) were significant determinants of community participation in EPI programmes. Moreover, EPI programmes in Elmina Subdistrict may not be achieving its goals due to low participation by the community members. The health workers are encouraged to enhance collaboration between them and community members to increase community participation in EPI programmes.

Chapter One


1.1 Background of Study

In community development programs, community engagement now appears to be the “software.” Community participation as a developmental strategy is an important cog in the wheel of ensuring that community programs are well-planned, implemented, monitored, evaluated, maintained, managed, and financed for the benefit of the current generation and future generations, using human, natural, and man-made resources (Putman, 2000). There is no single definition of community engagement; rather, there are a plethora of definitions that vary based on the degree of participation. In this continuum, “participation” spans from minor or “co-opted” participation, in which community members serve as token representatives with no say in decision-making, to “collective” action, in which local people start actions, set agendas, and strive toward a common objective. The term “community participation” is frequently used to refer to merely asking people about their health needs. Delegating the actual planning execution and pretesting programs are key components of planning, and opinions are frequently limited to prepackaged formulas (Brunner, 2001). Community participation has been used in the Expanded Programme on Immunization activities as a proven strategy for tackling healthcare challenges. The quality of participation, on the other hand, differs from program to program. Moreover, despite the failure of many health programs that were developed without the input of target communities or groups, some experts continue to dispute the relevance of community members’ participation in the development, implementation, and evaluation of programs (Adinku, 2000). As a result, it is advocated that involvement be improved in two areas: setting realistic expectations between communities and health services in terms of their contributions to health and in health system governance.

Dialogue between health-care providers and communities about their respective roles and the technical, resource, and social inputs required to fulfill them. The practical implementation of meaningful forms of participation has been hampered by ambiguous or vague roles, restricted authority, limited information availability, and weak representativeness, among other problems (Green & Ottoson, 1999). When several social groups demand that policymaking and execution be held accountable to the public, participation is frequently directed at management and implementation of systems. The term “participation” covers a wide range of connotations and goals. To some, it connotes a technique for increasing program efficiency or lowering costs, improving program sustainability, and developing local skills and knowledge essential for future interventions. This type of participation is a means to other development “ends,” a way to better attain goals and objectives. Participation, on the other hand, is viewed as a goal in and of itself, as it creates networks of solidarity and influences the decisions that affect their lives, legitimizing policy and practice, ensuring that they are more closely aligned with perceived public needs, and bolstering the incorporation of local knowledge (Marmot & Wilkinson, 1999).

Despite this, and despite the fact that participation is frequently used as both a means and an end in health policy, it is poorly operationalized in both health governance and accountability, as well as technical health interventions, so there is little systematic analysis of its specific contribution to health and health system outcomes (Green & Ottoson, 1999). The impact of collective action on community members is explained by community participation theories. According to the theory, community programs entail some form of collective activity on the part of the target group. The determinants of people’s participation make up a large group of determinants of action collection or subset. Oslon (1991), Buchanan and Tullock (1995), and McClusky (1995) investigated some of the theoretical approaches to collective action development (1990). According to community health theory and practice, planning is best done by people who will be the recipients of, or affected by, the resulting programs, policies, or services. A number of cases show a direct link between community engagement and health outcomes control. These findings suggest that improved prevention, treatment adherence, and rehabilitation necessitate participation. Public and professional concern over declining quality, access, and equity in health services, as well as increasing demand for people to finance and contribute to health services, community participation of both organized and unorganized groups is widely argued to be an important factor in improving health outcomes and the performance of health systems (Green & Ottoson, 1999). Rattray, Brunner, and Freestone (2002) developed a framework that describes the community participation ladder and provides a framework for health managers to plan, evaluate, modify, and extend their community engagement approaches in health programs. The year 2008 celebrated the 30th anniversary of Primary Health Care (PHC), the World Health Organization’s (WHO) health-care policy (WHO). One of the policy’s main tenets was community participation. “Community” is crucial in the context of public health, according to MacQueen et al. (2001).

  1. At the community level, prevention and intervention are carried out.
  2. Community is a significant factor in health outcomes.

Immunization is defined as the artificial creation of disease immunity. Antiserum injections provide temporary passive immunity, whereas active immunity is achieved by causing the body to create its own antibodies. This is accomplished by the use of antigens that have been processed (vaccination or inoculation). Vaccines work by stimulating the body’s own immune system to safeguard the person from illness or sickness in the future. Vaccines are used to immunize people and can be made from live bacteria, viruses, dead organisms, or their by-products (Geddes & Grossette, 1997). As a result, vaccination coverage is an important performance metric for the entire health sector. Several factors influence or contribute to effective community participation in the EPI program. Community-based factors such as formal education, perspective, attitude, and religion, program-based factors, and health-worker factors are only a few of them. It’s crucial to look into the processes that influence involvement in a community-wide intervention once more. According to the Ghana EPI Review (2004), protection of children at birth from neonatal tetanus was very inadequate in the Central Region, with a total regional performance of 12.6 percent. Tetanol Toxoid card conservation was also 39.2 percent, with a 12.8 percent vaccine dropout rate. These poor results were attributed to low community engagement as a result of community members’ refusal to fully embrace the EPI program. According to a study conducted at Kano University in Nigeria, immunization rates in African countries have been as low as 30% in some areas participating in the program during the last decade (National Programme on Immunization, 2007).

The absence of capacity building in interpersonal skills for health professionals, as well as the existing immunization schedules of the health system, were determined to be major inhibitors to a successful immunization campaign. Three factors were cited by MacQueen et al. (2001) as to why incorporating community engagement into health programs was so difficult. These explanations include:

  1. The use of a participatory planning tool as an intervention;
  2. Lack of in-depth examination of community people’s perspectives on the implementation of health programs such as the Expanded Immunization Program (EPI).

Difficulties to community engagement in EPI, according to MOH (2002), fall into three categories: hurdles with the program (or agency), obstacles within the community, and obstacles with society. Physical, biological, economic, political, social, cultural, and historical barriers might also be considered. Immunization is frequently viewed as a public health intervention in terms of vaccine availability and cost, storage and handling, and the ability to prevent, control, and monitor diseases. Communication efforts should be inextricably linked to and complement the other immunization technical components, including provision and quality of services, health worker capacity-building and skills, disease reporting and surveillance experts and communication specialists, according to recommendations from the Ghana EPI Review (2004a). One issue that program managers have is determining how to assess community engagement. What should be examined in particular in a health-care program? Community engagement must be able to facilitate rather than direct a process. Program managers and implementers should be able to seek out local expertise and build on it as needed, reinforcing knowledge and abilities. Community participation by community members is one of the techniques put in place to help meet targets established on the EPI program at the Komenda-Edina-Eguafo-Abrem (KEEA) sub-District levels. It will be crucial for program managers to establish and track participation metrics. One of the EPI program’s objectives is to achieve high community participation in the program. As a result, it’s critical for EPI program health planners to track changes in community selfefficacy or local capacity to detect and remedy problems (Green & Ottoson, 1999). Despite the fact that the EPI program has received tremendous support from a variety of governmental and private organizations, including the WHO, the Global Alliance on Vaccines, the World Bank, the Vaccine Industry, and others, there are some barriers to community participation in the EPI program in the Elmina sub-District (Clements, Greenough & Shull, 2006).

1.2 Statement of Problem

Over the years, the District Health Management Teams (DHMTs) and Regional Health Management Teams (RHMTs) have worked to engage communities in health-related activities. During talks at two consecutive District Annual Review Meetings conducted in Elmina in 2007 and 2008, it became obvious that communities were not participating in EPI programs as intended. The majority of health-care providers expressed concern that communities do not use immunization services. Effective community participation in EPI programs would enable service providers to reach every eligible kid in the EPI program and fully immunize them against childhood immunizable illnesses (Ghana Health Service, 2008). According to reports from service providers in the Elmina sub-District on community participation, (a) community members do not come for EPI services during outreach services, (b) pregnant women, mothers, and care givers do not come for routine immunization services as expected despite the fact that immunization is free, and (c) community members do not appear to be ready to mobilize and organize (Elmina Urban Health Centre, 2011; 2008). In Elmina, the DHMT (KEEA) and SDMT have attempted to organize district assemblies, community development, area committee members, the women’s wing, and other sectors in order to increase community engagement in EPI operations. To support this, every year a week is set aside (called “Health Week”) to enhance community awareness of health issues and programs through health education campaigns. All of these measures have failed to have the anticipated effect of encouraging communities to participate actively in EPI activities.

1.3 Objective of Study

Generally, this study seek to evaluate expanded programme on immunization and the factors influencing community participation. Specific objectives are stated below.

  1. To assess the extent of community involvement in EPI.
  2. To examine if community members in the Elimina sub-district participate in EPI differently depending on their educational level.
  3. To investigate community-based factors influencing community participation in the EPI programme in Elimina sub district.
  4. To ascertain whether health worker factors influences community participation in EPI programme in Elmina Sub-District.

1.4 Research Question

The following research question guides this study:

  1. What is the extent of community involvement in EPI in Elmina SubDistrict?
  2. Do community members of Elmina Sub-District participate in EPI in different ways depending on their educational levels?
  3. What are the community-based factors influencing community participation in the EPI program?
  4. Do health worker factors influence community participation in EPI programme in Elmina Sub-District?

1.5 Research Hypothesis

  • Ho: The level of community participation in EPI in Elmina SubDistrict is low.
  • Ha: The level of community participation in EPI in Elmina SubDistrict is high.

1.6 Significance of Study

The EPI programme needs high community participation in order to achieve its expected goal. Therefore, it is vital for health planners to measure changes in community self-efficacy or changes in local capacity to identify and solve problems facing the EPI programme. The findings may be useful to stakeholders such as the regional director of health services, SDHMTs, DHMTs, communities, and some policy makers like the public health division (GHS) for review and to be used to improve community participation in EPI activities. This study will therefore add to the existing literature on factors that influence community participation in the EPI programmed. Again, the study will serve as a platform for further investigation into community participation in EPI programmed in Ghana. Findings of the study would also serve as a guide for future researchers in the field of health in Ghana.

1.7 Scope of Study

This study focuses on assessing the extent of community involvement in EPI. The study will also examine if community members participate in EPI differently depending on their educational level. And lastly investigate community-based factors influencing community participation in the EPI programme. Based on the nature of the study, it will therefore be delimited to selected health care centre in Elimina sub district in Ghana.

1.8 Limitation of Study

Finance, inadequate materials and time constraint were the challenges the researchers encountered during the course of the study.

1.9 Definition of Terms

Community Participation:

Is the process by which individuals, families, or communities assume responsibility for their own welfare by contributing actively to planning, implementation of health intervention programmed in their communities (Burns, Heywood, Taylor, Wilde & Wilson, 2004).


This comprised a group of people with similar or near similar socio-cultural or ethnic identities, and values.

1.10 Organization of the Study

This research work is organized in five chapters, for easy understanding, as follows.

  • Chapter one is concern with the introduction, which consist of the (overview, of the study), historical background, statement of problem, objectives of the study, research hypotheses, significance of the study, scope and limitation of the study, definition of terms and historical background of the study.
  • Chapter two highlights the theoretical framework on which the study is based, thus the review of related literature.
  • Chapter three deals on the research design and methodology adopted in the study.
  • Chapter four concentrate on the data collection and analysis and presentation of finding.
  • Chapter five gives summary, conclusion, and recommendations made of the study.

Chapter Five

Summary, Conclusions and Recommendations

The purpose of this study was to find out the factors influencing community participation in EPI in Elmina sub-District of Ghana. This chapter focuses on the summary of the entire research, findings, conclusions based on the findings of the study, and relevant recommendations for the further actions.

5.1 Summary

Community participation appears to be the vehicle or platform for community development programmed. Community participation is a developmental approach essential wheel of ensuring that community programmed are well thought out, executed, monitored, evaluated, maintained, managed, financed, using human, natural and man-made resources for the benefits of the present generation and posterity (Putman, 2000).

Many researchers and community development agencies have identified community participation as a proven approach to addressing healthcare issues and has been utilized in the Expanded Programme on Immunization activities (Adinku, 2000; Burns et al., 2004; Cheetam, 2002; World Bank, 1994). However, the quality of participation varies from programme to programme. Moreover, in spite of the failure of many health programmed designed without participation of target communities or groups. On the other hand, some professionals also continue to question the value of community members’ participation in programmed designed, implementation and evaluation (Adinku, 2000).

As community participation is core to the success of many community health intervention programmed (Wehmeier, 2003), there are many factors that affect the planning, implementation, evaluation and the achievement of the goals of the programmed. These factors range from programmed formulation, planning, execution, evaluation and the involvement of the community members in the stages of the programmed (Daley et al., 2006; Fredrickson et al., 2004; Viswanathan et al., 2009). Other factors influencing community participation may include attitude of programme implementation professionals (health workers), programme resources management, educational levels of the community members, and the collaboration process between health workers and the community members (Shinitzky & Kub, 2001).

The framework for this study was in five phases, chapters one, two, three, four and five. Chapter one focused on the incidences that exposed community participation and the factors that influence community participation, with the emphasis on EPI programmed. The chapter also presented five research questions and two hypotheses that were formulated to guide the study. Then chapter two reviewed the related literature pertaining to community participation and factors influencing it. This same chapter contains synthesized pertinent theories related to community participation. In addition, the chapter highlighted the PMT as the theoretical base for this study.

The study was a survey in which data was collected from both community members and health workers at Elmina Sub-District. The community members (279) were conveniently selected while the health workers (19) were purposive sampled for the study. The researcher developed two questionnaires, community members’ questionnaire and health worker questionnaire, for the study. Community members’ questionnaire was pilot tested and taken through construct validity using principal component factor analysis (CFA) with orthogonal rotation (Varimax). The questionnaire yielded three constructs namely; community participation (α = .96), community-based factors (α = .85) and health worker-based factors (α = .86).

Frequencies, percentages, means and standard deviations were used to analyze participants’ background information. Additionally, means, standard deviations, and ANOVA were calculated to analyze research question two. Moreover, Schefe’s post hoc analyses (multiple comparisons) were calculated to determine where, among the groups, the differences existed. Also, effect size using eta square (η2) was calculated to determine the practical significance or the magnitude of the differences among the groups with statistically significant differences.
Key Findings

The following findings are derived based on the results of the study;

  1. Community members’ participation in EPI programmed was low in Elmina sub-District of the Central Region of Ghana
  2. Community participation in EPI programmed is dependent largely on community members’ educational status. Thus, community members with low level of educational attainment participated higher in EPI programmed that their higher educated counterparts.
  3. Community-based factors are useful determinants of community participation in EPI programmed.
  4. Health worker play significant roles in determining community members’ level of participation in EPI programmes.

5.2 Conclusions

EPI programmed in Elmina Sub-District may not be achieving its goals, for covering as many children as possible to preventing preventable childhood killer diseases, due to low participation by the community members. Effective collaboration between implementers (health workers) and the receivers of community health interventions (community members) is very critical to achieving community health intervention project goals, thus, to enhance health status of the community members, especially among children.

5.3 Recommendations

Based on the conclusion of the study the following recommendations were drawn;

  1. The health workers are encouraged to enhance their collaborative efforts between themselves and the community members in all stages of EPI programmes.
  2. Elmina Sub-District Health Directorate needs to step up efforts to providing health education to the community members on the EPI programmed and the need to actively partake in the programmed.

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