Using Community Theater to Improve Demand for Vaccination Services in the Niger Delta Region of Nigeria

"The project set out to explore the potential of using storytelling and emotion in increasing demand for vaccination services and emphasizing how emotions can be harnessed to create long-lasting positive behavior change."

Community theatre has proven to be an effective tool for promoting behavioural change communication. When used effectively, it has the potential to enhance understanding and awareness of health issues, address misconceptions, shape beliefs and attitudes that impact behaviours and social norms, demonstrate recommended practices, promote use of services, encourage action, and foster community support for recommended practices. Human-centred design (HCD) is an approach to delivering theatre performances that foster community engagement and ownership. The end users actively participate in all four HCD phases: discover, define, develop, and deliver. The aim of this study was to educate caregivers on vaccines and vaccine-preventable diseases (VPDs) and to empower them to seek immunisation services as a right by engaging them through an HCD process of trust building using community theatre as a tool in Bayelsa and Rivers States in the Niger Delta region of Nigeria.

The idea for the quasi-experimental intervention, Community Theater for Immunization (CT4I), was birthed after a chance encounter with Mama Koko, a 36-year-old rural fisherwoman who lived in the heart of the Niger Delta region of Nigeria and who had just lost her 3-week-old baby. During the encounter, Mama Koko talked about her pain and her regrets, having watching her baby suffer convulsions and eventually die from neonatal tetanus, a disease that vaccination could have prevented. HCD works with women like Mama Koko to co-create content that educates and amplifies stories that can increase demand for vaccination. Through the telling of stories using acting, singing, dancing, and spoken poetry, theatre can actively engage the audience, capturing their attention and immersing them in a meaningful experience. It creatively delves into shared beliefs and diverse perspectives, and it facilitates open discussions on sensitive topics. Theatre transcends literacy barriers and has the ability to engage individuals on both emotional and intellectual levels.

CT4I was deployed in 18 selected communities with low immunisation uptake between November 2019 and May 2021 in the 2 states. Four broad themes implicating user and provider factors emerged from the 18 focus group discussions (FGDs) as responsible for low immunisation uptake in the communities. These 4 themes were: awareness, trust, motivation, and action. In short, both demand- and supply-side factors were identified as responsible for poor vaccination in the intervention communities. "These engagements with the people help to 'discover' the problem and to define it more explicitly in the spirit of human-centered design thus giving opportunity to iterate lessons that were used in developing and improving the intervention."

In the intervention localities, relevant stakeholders (including the leadership of the health system), community leaders, health workers, and community members were engaged and actively involved in the design and performance of the theatre productions. As part of the process, 29 storyboards addressing barriers to immunisation uptake in the communities were developed. A hero's journey was co-created and clearly mapped out for each performance with 2 distinct hero's journeys: a caregiver's journey and a health worker's journey. The selection of key actors - rural women and community members - was done with recommendations from caregivers. The community cast were then trained on VPDs, vaccination services, and key vaccination messages. They were also trained on theatre performance and rehearsed using ad-lib dialogue in line with the storyboard and scenes that mapped the hero's journey. The creative team formed tales that projected the anxieties of the caregivers while delivering pertinent answers to their concerns. The team introduced their traditional songs, dances, and drumbeats and allowed the performers to act in their local languages to remove communication barriers. During rehearsals, ideas and suggestions from the community cast were incorporated into the co-created art piece, whose purpose was to increase awareness, rebuild trust, and motivate pregnant women and caregivers to actively demand vaccination services.

The content showcased real stories, using an HCD process of ideation, co-creation, rapid prototyping, feedback collection, and iteration. For instance, having researched, ideated, conceptualised, and built theatre performances that hopefully better fit within the lives of caregivers and communities, the organisers changed locations where theatre performances occurred, with a significantly higher leaning toward religious houses and meetings of women's groups, complemented by performances at routine community dialogue meetings. The theatre performances included scenes that:

• Worked to make people feel awe, the overwhelming positive feeling of being diminished in the presence of something greater than the self - focusing on the role of vaccination in attaining health for the entire community;
• Used humour, which captures the attention of an audience to drive belief and behaviour change toward an issue - comedy being relatable, evocative of positive emotions, and able to transport the viewer into the story;
• Sought to demonstrate pride, which has been found to be effective in motivating people to engage in altruistic behavior to improve their image of self in the eyes of others and to feel better about themselves; and
• Told stories that tapped into universal values and emotions, like love for children and wanting to protect one's family, which were amplified by showcasing positive deviance in the use of vaccination services.

An additional part of the performance was the discussion session and interpersonal communication facilitated by health workers to answer further questions from the caregivers and provide clarifications for the messages passed along during the theatre performances. In addition, there was an application of service design in the planning and organising of people, infrastructure, communications, and material components of vaccination outreach conducted at the close of the theatre session in order to improve the value, convenience, and interaction between health workers and caregivers. This component not part of the original solution but was a change made to the solution after initial rounds of user research. At the end of each performance, experiential feedback was collected on the user's experience during the play using a CoroSurvey App specifically developed for the intervention. The caregivers who served as community cast were charged to serve as community champions for routine immunisation and to lend their voices to educate other caregivers and share accurate information on routine immunisation in their communities.

The study involved all women of childbearing age (15-49 years) in the selected communities who were pregnant or had children 0-24 months of age and had lived in the community for at least 6 months prior to the pre-intervention household survey. The intervention included participation as community cast and community champions; the audience for the performances was left open to all community members.

A mixed-method approach was used for data collection. In the 2 states, 56 immunisation managers and 59 traditional and religious leaders were engaged. The intervention apparently led to a decline in the proportion of women reporting lack of information as a reason for their child's incomplete vaccination; accordingly, of the 217 caregivers trained on routine immunisation and theatre performances, 72% demonstrated a knowledge increase at the post-test. Lack of motivation also diminished, albeit inconsistently, across the survey periods.

A total of 29 performances attended by 2,258 women were staged, with 81% of the engaged community members reporting feeling more accepting of vaccine for their children following CT4I. At the performances, 270 children received vaccine shots (23% were zero-dose). There was a 38% increase in the proportion of fully immunised children in the communities and 9% decline in the proportion of zero-dose children from baseline.

According to organisers, dissemination meetings enabled the state immunisation leadership to see the depth of the reasons behind vaccine hesitancy among caregivers in the states and the extent to which the intervention had helped to address the barriers to vaccination demand in the intervention communities.

The researchers note that sustaining an intervention like this may be a challenge without some incentive for the actors, who had to sacrifice their time for training, rehearsals, and the actual plays. Since about one-third of play participants were willing to pay some amount of money to watch the play, money generated from there could be used to incentivise play actors and to aid the organisation of future performances.

In conclusion: "Communities were engaged to take the lead in identifying some of the demand-side challenges and barriers to demanding immunization, and these topics formed the foundational themes around which drama episodes were developed. Ultimately, the intervention leveraged the power of story-telling and the potential role of design thinking to address the global challenge of increasing demand for vaccination."