Roles of Mobile Teams in Tracing Lost to Follow-up Clients: Evidence from the Optimization of COVID-19 Vaccination Uptake and Routine Immunization in Ekiti State

"The mobile team has greatly educated people. Going to these communities have allowed us to reach people we can't even imagine. If we asked them to come, they wouldn't." - health worker

The routine immunisation (RI) system was greatly impacted by the COVID-19 pandemic, leading to a noticeable decline in vaccination coverage across many countries. The COVID-19 pandemic also influenced a rise in misinformation around existing vaccines, such as polio, and, in some situations, reduced trust in health services. To mitigate the impact of COVID-19 on low- and middle-income countries (LMICs), necessary steps were taken to develop a balanced approach that integrates COVID-19 into routine vaccination. In an attempt to optimise COVID-19 vaccination and RI via integration in some selected local government areas (LGAs) in Ekiti state, Nigeria, the Sydani Group, with the support of the United States Centers for Disease Control and Prevention (CDC) and in collaboration with the Ekiti State Primary Healthcare Development Agency (ESPHCDA), engaged 47 mobile teams to trace under-1 children who are lost to follow-up for immunisation uptake. This study seeks to explore the role of these mobile teams in tracing clients lost to follow-up for immunisation.

A 6-member team of health workers (2 vaccinators, 1 social mobiliser, 1 validator, 1 electronic management of immunisation data (EMID) recorder, and 1 paper recorder) made up what was known as the mobile team or outreach team. They traveled to different communities, particularly in remote communities and settlements where caregivers may either not be entirely informed about RI or are reluctant to visit health facilities, with 2 Geostyle boxes (used to carry vaccines). These separate boxes helped to distinguish RI antigens from the COVID-19 vaccine, avoiding mixup, and also to divide the responsibilities between the 2 vaccinators on the team to ensure equitable access to vaccines for children and adults. This approach was influenced by the learning acquired from the training offered to health workers. The study emphasises the importance of onboarding and/or training health workers across all categories involved in public health programme implementation, regardless of their existing knowledge.

The qualitative study was conducted across 9 LGAs in Ekiti state, Nigeria. Focus group discussions, in-depth interviews, and key informant interviews were the selected methods of data collection. Participants were 107 health workers at the community, facility, and LGA levels, as well as caregivers in some of the communities (close to the facilities) where adults and children were traced for vaccination. 

The study found that health workers at the community and LGA levels have a good knowledge of tracing clients lost to follow-up. They reported tracing lost-to-follow-up clients to connote keeping up with defaulters, through available information initially provided to health workers, to ensure their vaccination and/or immunisation. Findings revealed that a vaccination card is an important tool for tracing defaulters to get them vaccinated, as it contains vital information on locating the vaccinee.

Tracing lost-to follow-up clients reportedly resulted in two major successes: increased awareness of COVID-19 vaccination and RI, and improved vaccination coverage for both categories of vaccinees. Participants highlighted that community health workers have significantly heightened awareness for COVID-19 vaccination and RI, and, in the course of spreading awareness, the health workers found an unusual community (people who move around unclad), wherein the residents are not the usual kind of people health workers come by in their daily routine of mobile awareness for optimised vaccination and immunisation knowledge. Participants believed that the mobile teams' visitation to several communities established a foundation of vaccine accessibility to diverse categories of individuals in the communities

Participants highlighted that on several occasions they collaborated with community leaders to foster conviction on the part of community members that COVID-19 vaccination and RI have value. Participants also added that collaboration with community leaders helped address the issue of language barriers. Participants also collaborated with other health workers at the primary healthcare facility and outside the primary healthcare system to ensure optimum coverage. 

In addition, financial support acted as a form of motivation for community mobile teams.

Distance between communities and transportation were interdependent issues reported by health workers as challenges in the course of their duties. Also, participants highlighted that their lives felt threatened and pointed to an instance where members of a particular community sternly warned them not to return. Finally, participants reported the inaccessibility of some clients as a challenge. In many cases, the residential addresses provided on their vaccination card are sometimes not correct, and the phone numbers might be completely unreachable.

While tracing clients lost to follow-up is highly useful in identifying caregivers and children who are defaulting in their respective doses of vaccines, the study also assessed the conditions that can lead to caregivers' absence from visiting the health facilities for a subsequent vaccination of their children. For example, participants cited adverse events following immunisation (AEFIs) as one of the conditions hindering caregivers from visiting the health facilities for subsequent uptake of their children's immunisation. A caregiver further highlighted that her husband instructed her not to visit the facility for follow-up vaccination because of her child's AEFI experience.

In conclusion: "This study recommends that health workers across all levels, in collaboration with key players and stakeholders (including political office holders, traditional leaders, religious leaders, and other influential figures) should employ human-centered designed approaches (taking cues from agile innovation technique) to improve the sensitization of caregivers, and community populace on the values, benefits, and significance of the COVID-19 vaccination and routine immunization uptake."

Full list of authors, with institutional affiliations: Saheed Dipo Isiaka, Sydani Institute for Research and Innovation; Dapo Awobeku, University of Bristol; Akolade Uthman Jimoh, Sydani Initiative for International Development; Mahfus Dauda, Sydani Institute for Research and Innovation; Olugbemisola Wuraola Samuel, Sydani Institute for Research and Innovation; Stephen Olabode Asaolu, Sydani Institute for Research and Innovation; Oluwafisayo Azeez Ayodeji, Sydani Initiative for International Development; Sunday Atobatele, Sydani Initiative for International Development and Sydani Institute for Research and Innovation; Segun Adenipekun, Bill and Melinda Gates Foundation; Chukwudinma Okoh, Sydani Initiative for International Development; Zubair Adegoke; Sidney Sampson, Sydani Initiative for International Development and Sydani Institute for Research and Innovation