Document Type

Dissertation

Graduation Date

12-2025

Degree Name

Doctor of Public Health

First Committee Member

Ariane Rung, PHD, MPH

Second Committee Member

Nicole Kolm-Valdivia, PhD, MPH, CHES

Third Committee Member

Anthony Blake, DrPH, MPH

Fourth Committee Member

Eugene Lam, MD, MPH, MS

Abstract

Background: Vaccine-preventable diseases (VPDs) continue to be a major cause of illness and death in low- and middle-income countries, where system inefficiencies lead to missed vaccinations and delays in VPD case investigations. In Uganda, these problems persist despite high vaccine coverage rates. This dissertation assessed two innovations within the Growing Expertise in E-Health Knowledge and Skills (GEEKS) program: the tickler system, a paper-based tool for tracking immunization defaulters, and the electronic Integrated Disease Surveillance and Response (eIDSR) system, a digital surveillance platform. The study aimed to evaluate their effects on completing multidose vaccines and the timeliness of VPD case investigations.

Methods: A convergent parallel mixed-methods design was used to combine quantitative and qualitative data. The quantitative part utilized a quasi-experimental pre–post analysis to compare immunization completion rates (DTP1–DTP3) before and after implementing the tickler system in 10 health facilities, and to assess the timeliness of acute flaccid paralysis (AFP) case investigations before and after introducing the eIDSR platform. The qualitative part involved semi-structured interviews with stakeholders to identify implementation barriers, facilitators, and user experiences. Descriptive statistics, inferential testing, and thematic analysis were performed to evaluate system performance and contextual factors. Findings were integrated using the Consolidated Framework for Implementation Research (CFIR) and aligned with the Expert Recommendations for Implementing Change (ERIC) to develop evidence-based strategies for sustainable implementation and scale-up.

Results: The tickler system increased DTP3 completion from 61.8% to 71.1% (p < 0.0001), with children 42% more likely to complete the vaccine series post-intervention (aOR = 1.42; 95% CI: 1.13–1.80). Improvements were most substantial in small, rural facilities supported by mentorship and community engagement. Barriers included staffing shortages, documentation burdens, and limited funds for follow-up. The eIDSR system improved the odds of timely AFP investigations nearly fourfold (aOR = 3.78; 95% CI: 2.16–6.67; p < 0.0001). Users cited faster alerts and better coordination, but noted ongoing challenges of workflow duplication, unreliable SMS notifications, and reduced field incentives.

Conclusion: Both systems demonstrated measurable gains in immunization completion and surveillance timeliness. Sustainability requires integrating training, financing follow-up activities, addressing workforce capacity, and reinforcing accountability mechanisms. These interventions, when institutionalized, can strengthen Uganda’s progress toward the goals of the Immunization Agenda 2030 and the International Health Regulations (2005), advancing national and regional health security through more comprehensive and timely vaccination and disease surveillance systems.

Download

Available for download on Thursday, December 09, 2027

Share

COinS