*3.1. Individual and Household Characteristics of Clinic Users*

Our findings reflect the different urban populations served at the two container clinics. The exit interview responses revealed that approximately half of the caregivers attending the market clinic lived in the area (n = 25/45; 56%) in contrast to almost all the respondents from the fishing community clinic (n = 61/62; 98%) (Table 1). A higher percentage (13%; n = 8/62) of the caregivers attending the fishing community clinic were unemployed than the market clinic attendees; most women attending the market clinic were traders or head porters (71%; n = 32/45), and none reported unemployment. Additionally, maternal education levels differed at each site; almost half of the market clinic respondents (n = 22/45; 49%) reported receiving either no formal education or only primary school education compared to 20% (n = 13/62) of the fishing community caregivers. Caregivers at the market clinic were of a median age slightly older than that of the caregivers in the fishing community clinic (32 vs. 28 years old). The median age of the children attending was the same across both clinics (12 months).

For the qualitative portion of the evaluation, 34 individuals participated in the interviews and discussions, with 17 participants being from the fishing community, 14 from the market community, and three from the sub-metro health authority.


**Table 1.** Exit interview responses among caregivers of children 0–5 years of age from container clinics in two urban communities on the accessibility and acceptability of services offered 12 months post-implementation, September 2018 (N = 107).


**Table 1.** *Cont.*

\* Other responses included laborer, cook, housewife, artisan, apprentice, sanitation worker, teacher waitress, laundry worker, pedicurist, and binding shop worker. ˆ Denominators are determined by responses to a preceding question. \*\* Responses may exceed sample sizes as participants could provide more than one answer. Abbreviations: Do not know (DK), not applicable (NA).

The average age of caregivers who participated in the FGDs was 29 years for nonattendees and 26 years for attendees. Most participating caregivers were traders (62%) and head porters (19%). The average age of children whose caregivers were in the 0–23-month FGDs was 10.8, while that of children whose caregivers were in the 24- to 59-month group was 33.5 months.

#### *3.2. Infrastructure and Availability of Services at Container Clinics*

The infrastructure and services provided by both clinics evolved within the first 12 months. Each clinic was developed from an outreach post that provided immunization services once a month by vaccine carriers to an expanded clinic with official EPI reporting tools and EPI refrigerators on-site; full-time staff including 2–6 nurses offered daily routine immunization services. Moreover, at six months, both clinics offered two additional routine vaccines—the rotavirus vaccine (Rota) and pneumococcal conjugate vaccine (PCV)—to their catchment populations, and the newly introduced inactivated polio vaccine (IPV) at 12 months post-implementation (Table 2). This infrastructure improvement was noted during the nurse FGDs:

... *we used to suffer. Before we were doing the outreach without the container, you will be sitting there, sometimes before you even come, the rain has taken all your things, spoilt your registers, dust and all that; so when the container came it was really good.*—Nurse, the fishing community clinic

*At first, we used to go and carry it (vaccines) from the polyclinic before we come here. And so, by the time the mother will come, the vaccine is not here yet because they come here very early. Now, the moment you come, you just pick your vaccine into your carrier and start working.*—Nurse, the market clinic

The increase in the availability of services was matched by an increase in utilization. Over the first year, the number of monthly vaccine doses administered increased consistently. When comparing the first to last month of doses administered, we observed a 442% increase at the market clinic (28 to 152 doses) and a 239% increase at the fishing community clinic (66 to 224 doses). This change included doses of IPV (introduced in June 2018) and the newly offered PCV and Rota (Figure 2).


**Table 2.** Summary of services and clinic infrastructure offered by two container clinics preimplementation, and six months and twelve months post-implementation in the Accra Sub-Metro, 2017–2018.

Bold signifies new vaccines being offered at clinics. Abbreviations: Penta vaccine (diphtheria-tetanus-pertussishepatitis B-Haemophilus influenza type b vaccine); OPV (oral polio vaccine); MR (measles rubella vaccine), YF (yellow fever vaccine); Men A (Meningococcal Serotype A vaccine); Rota (rotavirus vaccine); PCV (pneumococcal conjugate vaccine); IPV (inactivated polio vaccine); DHIMS (district health information management system).

**Figure 2.** Panel line graph displaying total vaccine doses administered in two container clinics providing immunization services in Accra, Ghana, September 2017–September 2018. Total doses include Penta1-3, PCV1-3, Polio1-3, Rota1-2, MR1, YF, MR2, MenA, and IPV (introduced in June 2018). Abbreviations: "Penta" or Pentavalent vaccine (diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenza type b vaccine); OPV (oral poliovirus vaccine); MR (measles rubella vaccine), YF (yellow fever vaccine); Men A (Meningococcal Serotype A vaccine); Rota (rotavirus vaccine); PCV (pneumococcal conjugate vaccine); IPV (inactivated poliovirus vaccine).

When assessing measles-rubella dose 1 (MR1) and MR2 specifically, both container clinics exceeded their annual target population for MR1 and MR2. For example, at the market clinic, the target population for 12–23 months was 150 children, and 180 doses of MR2 were administered. At the fishing community clinic, the target population for 12–24 months was 110 children, and 153 doses of MR2 were administered (Figure 3). The nurses also described an increase in vaccine uptake among the target population and improved immunization service utilization for traditionally underserved populations:

*It has really increased because we are actually now getting more than what we used to get. Like now, what we get in a week is more than the number we used to get for a month.*—Nurse, the fishing community clinic

... *let's take the kayayei, they sleep here unless festive seasons before they go to their places but some people too those who are from northern region, their vaccination is very poor because sometimes a five year old hasn't taken Penta 3, no vitamin A at 6* ... *when you go for visit you can look out for them and give them the vaccines.*—Nurse, the market clinic

**Figure 3.** Stacked bar graphs displaying doses administered over time for measles-rubella-1 (MR1) and measles-rubella-2 (MR2) at both container clinic sites from 2017–2018. Abbreviations: MR1 (measles rubella vaccine dose 1); MR2 (measles rubella vaccine dose 2). Note: missing data for the market site in November 2017.
