Impacts of Engaging Communities Through Traditional and Religious Leaders on Vaccination Coverage in Cross River State, Nigeria

"Policymakers need to consider interventions that drive demand for vaccination to ensure optimal uptake of vaccination even among the possible resistant groups in the community."

A 2017 survey showed that only 21% of children 12 to 23 months of age are fully vaccinated in Nigeria. Several reasons contribute to low coverage, including poor parental knowledge and attitudes. In Nigeria, previous studies have shown that engaging traditional and religious leaders (TRLs) as agents of change to tackle misguided parental norms about polio vaccination improved uptake. TRLs are respected in their communities as opinion-shapers and guides in religious, social, and family life. This study, funded by the International Initiative for Impact Evaluation (3Ie), evaluated a multi-component intervention that involved training TRLs to engage communities in the planning, implementation, and monitoring of immunisation services in Cross River State, Nigeria.

Before the intervention, the role of TRLs in immunisation services was limited to mobilisation of the communities for immunisation campaigns. This intervention sought to strengthen TRLs and Ward Development Committees (WDCs), the main structure in the Nigerian public health care system, in the following ways:

• The TRLs underwent an education programme that included topics such as leadership styles, effective communication, disease prevention through vaccination, and mobilising communities for routine immunisation (RI). The sessions were interactive and participatory. Methods of training adopted included brainstorming, large and small group discussions, role plays, problem solving case studies, and use of learning aids.
• Frontline health workers, known as community health extension workers (CHEWs), were trained on using infographic techniques to summarise and present monthly data on routine immunisation for their catchment area on a portable dashboard that was shared with TRLs and other community leaders during WDC and other leadership meetings. CHEWs were also trained on managing cases of adverse events following immunisation.
• Operations of the WDCs in the intervention communities were streamlined for more effective resource mobilisation and oversight of the health facilities in their respective wards.
• A community engagement component took the form of routine community meetings where the TRLs educated their communities on vaccination.

Elements of the theory of change for this demand-focused intervention:

• The TRL training was based on the assumption that making TRLs realise their roles in delivering health care to their communities will stimulate them to support the health workers and create an avenue for a concerted effort between them to achieve their shared goals. This was to create a sense of ownership among the leaders and to promote the active participation of the communities in their health care.
• It was further assumed that since the TRLs are key community influencers, training them on vaccination and communication will enhance their ability to effectively communicate vaccination messages with their community members and to impact positively on the community's attitude towards vaccination of their children, with the intention of impacting on the indices of vaccination.
• Training was also expected to foster interaction between the TRLs and the health workers for ease of communication between them.
• Another assumption was that communities' knowledge of their RI performance will stimulate their interest to perform better and cause them to be the watchdog in their communities to ensure the unvaccinated among them get vaccinated.
• Health workers' training on preparation of user-friendly data was expected to support the data shared at the community meetings by the TRLs. By sharing the data, the communities could support the health workers in identifying the unvaccinated and defaulters in their midst.
• The intervention was expected to empower the TRLs to perform their gate-keeping role and provide effective leadership in the WDC towards increasing utilisation of immunisation services.

The study used 3-stage cluster random sampling based on administrative and geographical levels in Cross River State. There are 18 local government areas (LGAs) in the state, of which 8 were selected based on stratification. The strata were: north urban, central rural, south rural, mixed urban areas of the state. Two LGAs were randomly selected per strata, and one of each pair was randomised to control or intervention arms. At the second stage of random sampling, 3 wards were selected within each LGA. At the third stage of sampling, 4 villages were randomly selected within each ward, and, within each village, 25 children aged 0-23 months were selected for assessment of vaccination coverage.

In addition to the quantitative study, key informant interviews (KIIs) and focus group discussions (FGDs) were held at baseline and final evaluation phases of the intervention with key decision-makers in the community on vaccination issues. The key informants included primary health care (PHC) coordinators, the social mobilisation officer, and the ward focal person in the 8 selected LGAs. FGDs were held with TRLs, WDC members, and mothers that utilised vaccination services in the health facilities.

Twenty-four participants were trained in each of the 4 intervention LGAs, except in one of the study sites. This comprised all the village heads in the selected villages and the clan head from the selected ward and 2 religious leaders from each ward. The majority of the religious groups were Christians.

Baseline data were collected in December 2015 while tools were developed and piloted. The first phase of training was in May 2017. Five sessions were held within 9 months, halfway through the period of intervention. Midterm data was collected at the 9th month, and the intervention continued for another 9 months. Three sessions of training were held in the second half of the intervention. Endline evaluation took place in February 2019.

Main findings

• Although the intervention did not have a significant impact on full immunisation rates of children, the proportion of children who had received no vaccinations decreased in the intervention arm from 7% to less than 1%. In the control arm, the proportion of unvaccinated children remained constant at 10%.
• The intervention had a significant positive impact on the timeliness of receiving pentavalent and measles vaccinations. For penta 1 vaccine, the proportion of children vaccinated at endline increased from 46% to 60% and for penta 2 the proportion changed from 33% to 41%. The proportion of children receiving penta 3 on time increased from 24% to 29%; for measles, the figure rose from 19% to 41%. The timeliness rates in the control areas remained largely unchanged during the study period. There was a small (5%) but significant reduction in the dropout rate.
• There was some evidence that, following the training, there was more interest among the leaders in RI activities. For example, one community in Obudu LGA (Utugwang) built a bridge they called "monkey bridge" to facilitate access by the health workers to a hard-to-reach community; communities in Etung and Itu-Agwagune (Biase) hired boats for health workers to aid vaccination services. The training was also found to have provided an opportunity to foster stronger and focused interactions between the health team and TRLs.
• KIIs and FGDs did not reveal major changes in attitudes and beliefs of TRLs, health workers, or WDC members. The communities were generally knowledgeable and had positive attitudes towards vaccination. However, there were some reported instances of negative experiences and fear of side effects with vaccination, which adversely affected uptake of vaccines. ("More communication, particularly by the TRLs, on this will be required to change this notion among the caregivers.")
• Comparing the functioning of WDCs between treatment and control at baseline and endline, the study found that even though the WDCs in the control arm met regularly, immunisation-related outcomes did not change substantially in these areas. This observation led the authors to infer that the intervention may have prompted TRLs to regularly discuss RI during the WDC meetings in the treatment arm, which could have contributed to the observed impacts on immunisation-related outcomes.

The authors conclude that the TRLs are a form of untapped resource in the community who have the capacity to influence and support vaccination uptake. In particular, as key influencers, they may be able to address caregivers' fears about common discomforts associated with vaccination like fever and pain at the injection site. Therefore, vaccination programme managers and health workers involved in providing vaccination services in similar low- and middle-income country (LMIC) settings are encouraged to advocate for the active engagement of TRLs in the planning, implementation, and monitoring of RI. However, the authors also include a caveat on the interpretation and uptake of this evidence, as the intervention did not seem to have an impact on improving full immunisation rates. They call for further research into exploring the disproportionate impacts of this intervention on full immunisation rates.

Editor's note: A finalised version of this report was published in September 2020; click here to view or download it (68 pages).