On-the-job peer training of immunization nurses is a low-cost, effective way to increase the proportion of children vaccinated and to improve immunization practices, according to data from health centers in the Maluku province of Indonesia.1 The overall number of vaccinations against diphtheria-pertussis-tetanus (DPT), polio and measles rose by approximately 37% in participating health centers, at a cost of US$0.05 for each additional dose. In addition, participating centers reported a 38% increase in the number of procedures performed correctly.

To determine the effect of peer training on immunization coverage and practice quality, researchers evaluated a program in which experienced immunization nurses provided on-the-job training to less-experienced nurses. The program was conducted in 13 health centers in the Maluku province of Indonesia in 1993 and 1994; 95 centers that did not participate acted as a control group. The evaluation used retrospective data from the provincial health department's administrative information system, two province-wide field surveys (one in 1994 and one in 1995) and an independent field survey of immunization practices in 90 health centers.

In the intervention, experienced immunization nurses spent 1-2 weeks providing training at health centers in which nurses were inexperienced or were performing poorly. The trainers provided instruction on injection techniques, maintenance of vaccine quality (e.g., proper refrigeration and storage), data collection and reporting, and ways of enhancing immunization coverage (e.g., scheduling and follow-up strategies, and methods of motivating mothers and generating support from community leaders).

At the participating centers, the number of vaccine doses provided in the 11 months after the training was significantly higher than the number in the 11 months before the training. The overall number of DPT, polio and measles vaccinations rose by about 37%--the first course of DPT by 34%, the complete course of polio vaccine by 38% and measles by 40%. In the nonparticipating centers, the overall number of vaccinations declined by 1%, with DPT remaining the same, and measles and complete courses of polio decreasing by 2% each. The difference between participating and nonparticipating centers was highly significant overall and for each vaccine (p<.001).

In the 11 months after training took place, the proportion of children in the target population who were immunized at participating centers rose from 42% to 68%. The average percentage-point increase was 26: 27 points for DPT, 27 for polio and 26 for measles. The overall increase was almost 54% in the 11 centers that had a functioning transportation system during that year. In comparison, coverage at nonparticipating centers rose from 58% to 60%. The average increase was one percentage point overall--three points for DPT, one point for polio and one point for measles. The difference between the participating and nonparticipating centers was highly significant overall and for each of the three antigens (p<.001).

The training also had a positive effect on practice management. According to data from the field survey of immunization management practices, the average number of key immunization practices performed correctly rose from 7.4 (of 12 management practices surveyed) before training to 10.2 after training--an increase of 38%. Improvements were reported in protocol adherence, sterilization technique, data reporting, appropriate immunization practice and use of active problem-solving approaches to finding and vaccinating children in the villages.

The average cost of peer training--including travel and per-diem costs but not wages--was US$53 per immunization nurse; this expense ranged from US$16 to US$134, depending on training duration and travel costs. The number of reported doses increased by 12,745 in the 13 participating centers the year after the training, at a cost of about US$0.05 for each additional dose (around US$0.50 to complete all immunizations for one child).

According to the researchers, they cannot determine how much of the gain in coverage resulted from increases in the number of age-appropriate doses administered and how much from improved reporting: Based on available data, the two variables cannot be disentangled. They point out, too, that because these improvements were reported in poorly performing centers, it is unclear whether such improvements could be achieved in all centers, particularly those that are doing well. The researchers observe that the program's success depended heavily on the local area monitoring system, the hierarchy of responsibility of the health centers and immunization nurses, and the villages themselves. Noting that these supporting structures may not be available in other contexts, they caution that "the transfer of this training programme to other contexts may require extra care" or may not be successful.--E. McLaughlin


1. Robinson JS et al., Low-cost on-the-job peer training of nurses improved immunization coverage in Indonesia, Bulletin of the World Health Organization, 2001, 79(2):150-158.