Measles-rubella surveillance and its facilitators and barriers in Bagmati province, Nepal: A mixed methods study

Objective This study aimed to assess the status of measles-rubella surveillance and understand the facilitators and barriers for the measles-rubella surveillance activities in selected municipalities of selected districts of Bagmati province of Nepal. Design This is a convergent parallel mixed method study, incorporating both quantitative and qualitative approaches, was conducted in eight municipalities of the three districts (Sindhupalchok, Makwanpur, and Chitwan) of Bagmati province, Nepal. Setting Three districts from Bagmati Province were purposively selected to ensure ecological representation: Sindhupalchok (mountain), Makwanpur (hill), and Chitwan (Terai). Eight municipalities, including both rural and urban areas, were selected from the three districts. The health facilities included in the study were: a) All the health facilities that are part of the WHO reporting unit (RU) for Vaccine-Preventable Disease (VPD) surveillance b) purposively selected health facilities outside the WHO RU. Health facilities within each municipality were selected, ensuring representation of government hospitals, private hospitals, Primary Health Care Centers (PHCC), and Health Posts (HP). Participants From each selected district, one District Health Office Chief and one immunization and surveillance focal person were purposively recruited for Key Informant Interviews (KIIs), along with one health section chief from each selected municipality. A total of 14 KIIs were conducted with district and municipal stakeholders. For in-depth interviews (IDIs), two WHO-SMOs overseeing VPD surveillance and immunization activities in these districts, along with a VPD surveillance focal person from each selected reporting and non-reporting health facility, were purposively selected. Results The key strategies to achieve measles elimination, that is the MR2 coverage of 95%, was not achieved in most of the municipalities. The main barriers to effective VPD surveillance among others included limited awareness of VPDs under surveillance, poor understanding of the measles elimination target, and lack of clarity on standard case definitions for suspected measles-rubella cases. The major facilitators for effective VPD surveillance included awareness on the importance of VPD surveillance in measles elimination, availability of SCD posted in all reporting health facilities, and timely case notification and investigation by RUs. Conclusions Although, national immunization programme (NIP) is a priority 1 (P1) programme of the Government of Nepal, one of the key strategies (95% MR2 coverage) to achieve measles elimination was not achieved in most of the municipalities. This study suggests that measles-rubella surveillance in the study sites can be strengthened through capacity building of health workers in VPD surveillance, ensuring the availability of the VPD surveillance field guide, availability of the dedicated focal person, emphasizing in data analysis and utilization of surveillance data. Strengths and limitations of this study One of the major strengths of this study is the selection of districts from all three ecological regions of the country as it helps to ensure geographical coverage. It helps to increase the relevance of the results across similar ecological regions in Nepal. Similarly, our study also included both WHO reporting and non-reporting health facilities ranging different types of health facilities such as government hospitals, private hospitals, primary health care centers and health posts which helps to cover broader perspective on surveillance system. Likewise, wide-range of stakeholders (district health officers, municipal health staff, WHO-SMOs, and health facility focal persons) involvement in this study provides multiple viewpoints on facilitators and barriers of surveillance. Furthermore, this study included both rural as well as urban municipalities exploring the perspectives of focal persons from those settings. Despite all these strengths, there are also some limitations of this study, and one of them is purposive sampling of districts, municipalities and participants which may have introduced selection bias and which may also limit the generalizability to all parts of Nepal. Additionally, the study was restricted to three districts of only one province of Nepal (Bagmati), therefore, it may not capture nation-wide variance in measles-rubella surveillance. Reporting biases is also one of the potential limitations of this study especially in case of qualitative data collection from district health officers, municipal health staff, WHO-SMOs, and health facility focal persons because they may have provided socially desirable responses affecting the actual findings of KIIs and IDIs.