**1. Background**

Urbanization is rapidly increasing worldwide; it is estimated that by 2050, 66% of the world's population will live in an urban area [1]. Much of the increased urbanization is projected to occur on the African continent, where 56% of the population will be urban by 2050 compared to 37% in 2000 [1]. This vast transition to urban living has implications for health systems, and research has indicated significant health and immunization coverage disparities between the poorest urban communities and the wealthiest ones [2,3]. A systematic review of 63 studies conducted in 16 low- and middle-income countries (LMICs) identified that migration status, distance to health facilities, and a lack of parental awareness contribute to the low vaccination status of children living in urban areas [2]. Interventions designed to improve urban immunization coverage in LMICs have primarily focused on community outreach to improve the utilization of services through education, coordinating social mobilization activities, enhancing home visit services, or extending

**Citation:** Shaum, A.; Wardle, M.T.; Amponsa-Achiano, K.; Aborigo, R.; Opare, J.; Wallace, A.S.; Bandoh, D.; Quaye, P.; Osei-Sarpong, F.; Abotsi, F.; et al. Evaluation of Container Clinics as an Urban Immunization Strategy: Findings from the First Year of Implementation in Ghana, 2017–2018. *Vaccines* **2023**, *11*, 814. https:// doi.org/10.3390/vaccines11040814

Academic Editor: Pedro Plans-Rubió

Received: 17 February 2023 Revised: 3 April 2023 Accepted: 6 April 2023 Published: 7 April 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

clinic hours [4]. However, urban populations encounter additional barriers to accessing services, highlighting a need for novel strategies to improve access for vulnerable urban communities [2,4].

"Access" can be challenging to define within low-resource contexts in which the overall availability of healthcare is low [5]. Peters et al. (2008) described a framework for accessing healthcare in low-income countries [5] and defined four primary dimensions of access: availability, geographic accessibility, financial accessibility, and acceptability. These dimensions account for the unique experiences in accessing healthcare in LMICs and highlight that the "local adaption and experimentation" of new strategies is critical for improving access. Thus, considering this framework in the initial development and small-scale evaluation of an innovative strategy can improve subsequent implementations and research to enhance access to health services [5].

Immunization services in Ghana are provided at fixed sites (permanent health structures), as well as outreach sites—designated locations where nurses bring vaccine carriers from larger central facilities to deliver immunization services for the day. In comparison to the rural setting, outreach services in many urban settings are frequently not planned or conducted under the assumption that since distance is not as great between fixed sites and households in the urban setting, parents can easily find their way to the existing fixed sites. However, in the urban setting, access to fixed sites can be very challenging due to transport time barriers, transport cost barriers, and busy work schedules. One potential strategy to improve access to immunization in urban settings is the provision of readily accessible, flexible, and convenient, service delivery sites located near urban workplaces or vulnerable urban communities. Container clinics are cargo containers that are converted to clinics and can be used to provide stationary or mobile medical services [6]. These clinics are relatively easy to build, can be easily placed in strategic locations (such as at front of urban markets), and can be adapted to community needs. Container clinics have been utilized to provide infrastructure where health systems are fragile or nonexistent in post-conflict or disaster settings [6–8]. However, to our knowledge, none of the published studies have evaluated the feasibility of using container clinics as a strategy to increase the reach of routine immunization services.

In Ghana, as in many LMICs, disparities between urban and rural immunization coverage exist. A study of Ghana's 2008 and 2014 Demographic Health Surveys (DHS) indicated that children living in urban areas of Ghana were less likely to be fully immunized than children living in rural areas [9]. Furthermore, an analysis of Ghanaian unimmunized children in 2017 found that the urban districts of Kumasi, Accra, and Sekondi-Takoradi had the most unimmunized children [10].

To address the unique urban barriers in accessing immunization services, the Expanded Programme on Immunization (EPI) in Ghana opened two container clinics in the Accra Metropolitan area in September 2017. The clinics were established in nearby locations where nurses previously provided outreach immunization services once per month. They were outfitted to provide daily child health services, including immunizations, home visits, and other forms of preventive and curative care. The container clinics were a small-scale feasibility/demonstration project that fit into a broader initiative known as the Ghana's Second Year of Life (2YL) project [11]. To inform future scale-up in Ghana and their use in other countries, we evaluated community acceptance and the performance of these container clinics during the first year of implementation.

#### **2. Methods**

#### *2.1. Setting*

The two container clinics were established in a large Accra sub-metro area of Ghana, with an overall population of 151,712 (2017 estimate). The sub-metro is divided into five zones that house several health clinics, including a polyclinic, maternity house, and hospital.

Two of the five zones in the sub-metro were purposively selected container clinic sites. These zones were selected because of expressed community interest, population mobility and vulnerability, limited health infrastructure, and low immunization coverage. For both sites, community advocacy was a key factor in their selection because it is a known indicator of the success of interventions in urban settings [2]. The first container clinic, referred hereafter as the "fishing community clinic," was placed in a zone with a slum community, directly on the Atlantic coast with a large fishing industry. The second container clinic, referred to hereafter as the "market clinic," was placed in a zone with a large market in Accra, primarily serving kayayei (informal laborers who carry goods for shoppers at markets) and seasonal migrant workers from the northern part of Ghana. Notably, the selection of this site was also informed by recent research that indicated significant social, cultural, and economic barriers among kayayei women [12,13]. Both clinics were implemented in coordination with the Accra Metropolitan Health Authorities and with the support of community leaders. The clinics were situated on gifted land provided by those same community leaders (see Figure 1 for a picture of the market clinic).

**Figure 1.** Image of the market container clinic prior to opening in Accra, Ghana, September 2017.

The container clinics were built near the previously designated outreach sites. The two sites planned services for an annual catchment child population of 310 children (0–23 months of age) at the fishing community clinic and 422 children at the market clinic.

#### *2.2. Container Clinic Evaluation Design*

We used a mixed-method design to evaluate the changes in the immunization services provided at the two locations between September 2017–September 2018. The following information was captured and triangulated to provide initial data on the clinics.

#### *Infrastructure Assessment*

To describe the evolving infrastructure of the clinics during implementation, we collected data on immunization infrastructure (e.g., cold chain capacity) and the services provided (e.g., vaccines offered) at the sites before or at the time of the clinics' opening (September 2017), and then six months (March 2018) and 12 months after opening (September 2018).

#### *Monthly Number of Vaccine Doses*

Every month, we prospectively collected the number of vaccine doses and the type of vaccines administered at each site using the monthly administrative reporting forms (September 2017 to September 2018). We captured the number of vaccine doses administered to children of 0–11 and 12–23 months of age for the pentavalent vaccine (diphtheriatetanus-pertussis-hepatitis B-Haemophilus influenza type b) (Penta); oral poliovirus vaccine (OPV); measles rubella vaccine (MR), yellow fever vaccine (YF); meningococcal serotype A vaccine (Men A); rotavirus vaccine (Rota); pneumococcal conjugate vaccine (PCV); and inactivated poliovirus vaccine (IPV). Historical administrative records for these sites of when they were outreach posts were largely unavailable, although records from the fishing community site were available for the month prior to opening. Information on target populations for the catchment areas of both clinics were collected from administrative records and the nurses who worked at the outreach vaccination sites. These data were imported, aggregated, and tabulated using Microsoft Excel Office 365 Version 2208.
