The Use of Community-Oriented Primary Care (COPC) Model to Generate Vaccine Demand: The Case of a Remote Fishing Community in Cameroon

"What stands as a success-determining factor in this project is how integrated packages are developed and deployed to meet the needs of communities, build trust, and generate demand for services in these missed communities."

Cameroon, a country in sub-Saharan Africa, ranks among the top 15 countries worldwide with the highest number of zero-dose (unvaccinated) children. Among other reasons, pockets of hard-to-reach communities that traditionally miss essential healthcare services, including childhood immunisation, largely contribute to this sub-optimal vaccination coverage. This is the case of Manoka Health District (MHD), an archipelago district with a zero-dose proportion of 91.7%. High disease burdens such as malaria and water-borne diseases have forced the population to depend on herbalists and roadside drug vendors, eroding trust in the primary healthcare system and worsening vaccine hesitancy. This study describes how a project optimised vaccine demand generation in these hard-to-reach settlements using an integrated community health worker (CHW) service delivery package developed using the community-oriented primary healthcare (COPC) model.

• The COPC model has two elements - a community diagnostic phase and an iterative intervention cycle that allows for monitoring and evaluation of project implementation and course correction.
• In the diagnostic phase, the World Health Organization (WHO) health system pillars-guided baseline assessment was deployed to understand the gaps in community health delivery systems in MHD. In addition, a list of the top 10 health conditions was obtained from the district health services, CHWs, and community representatives. A scoring system was used to rank these health needs based on district priorities, the level of involvement of CHWs, cultural acceptability, and impact on vulnerable populations. 
  * As part of the intervention cycle, CHWs were also empowered on effective health promotion through home visits, during which CHWs screened for zero-dose and under-immunised children and referred them for vaccination in the nearest health post in other health areas. They also prepared a line list of unvaccinated children to be used during vaccination outreach sessions by the district health service. To enhance the self-efficacy of CHWs in serving the community, the mobile health team jointly offered basic health packages with the CHWs in the early phase of the project.

This cross-sectional descriptive study was based on data collected from November 2021 to August 2022 in three project-implementing health areas (Kombo Moukoko, Kooh, and Toube) in MHD. Data were collected on the integrated health packages offered by CHWs. It comprised health education on malaria and water-borne diseases, screening for malaria, treatment of under-5 for uncomplicated malaria and diarrhoea, conduct of essential antenatal care (ANC) services, and vaccination counseling and referral in the three health areas. Microsoft Excel 2013 was used to analyse descriptive data and expressed results as percentages, with tables and column charts used for data visualisation.

Over 550 under-5 children and 187 pregnant women were identified to be in need of curative and preventive care services during the project period. About 81% of pregnant women received a minimum ANC package by CHWs, and 47% adhered to referrals to health facilities for continuous ANC and delivery. Half of the children under 5 with health issues were diagnosed and managed for uncomplicated malaria. Also, during home visits, 617 under-immunised and zero-dose children less than 2 years of age were identified, referred, and vaccinated, either during an outreach programme or at the nearest health post in a neighbouring health area, representing about 64% (617/964) of under-2 children identified in these communities.

There was a gradual increase from 0% vaccine acceptance post-referral in the first month to 47% after six months and 64% at one year of intervention. This gradual increase in vaccine acceptance could be attributed to continuous access to information during home visits and trust building due to the presence of CHWs who are meeting the communities' priority needs. In addition, optimising outreach by providing a list of zero-dose and under-immunised children before outreach sessions improved uptake.

In conclusion: "The use of the COPC model to co-develop integrated essential health service packages that meet the needs of communities showed value in building trust and increasing childhood immunization uptake in hard-to-reach communities."