EFFECTS OF ENGAGING COMMUNITIES IN DECISION MAKING AND ACTION THROUGH TRADITIONAL AND RELIGIOUS LEADERS ON FULLY VACCINATED RATES: A CLUSTER RANDOMIZED TRIAL

MID-TERM EVALUATION BRIEF

Oyo-Ita AE, Bosch-Capblanch X, Ross A, Oku AO, Esu R, Oduwole O, Arikpo D, Soter A, Edet EE,  Moriam C, Odey F. Udo E, Meremikwu M

EXECUTIVE SUMMARY

This study provides preliminary data on the evaluation of the effects of engaging traditional and religious leaders and strengthening their capacity to participate in the planning and implementing vaccination services. The midterm evaluation shows that the intervention may reduce the number of unvaccinated children, improve community involvement in vaccination and the timeliness of vaccinations.

INTRODUCTION

Low childhood vaccination rates continue to be a problem in Nigeria. This has partially been linked with weak routine immunization (Ophori, 2014). One of the ways to strengthen routine immunization is mobilising people to generate demand through community and caretakers engagement (WHO, 2015). Traditional and religious leaders (TRL) are influential and are respected in their communities as opinion formers and guides in religious, social and family life. They have been used as agents of change to get communities to use health services. We believe that engaging the TRLs and the Ward Development Committee (WDC) members will improve their capacity to communicate information on vaccination to their community members and thereby mobilise them towards increased demand and timeliness of vaccination and consequently improve facility utilization.

Research goal

This research aims at determining the efficacy of a multi-component intervention to strengthen the capacity of traditional and religious leaders (TRL) as a means to improving uptake of immunization in selected communities in Cross River State, Southern Nigeria.

Objectives

To assess the effect of the intervention on:

  • The proportion of children aged 0 to 23 months who are fully vaccinated
  • The proportion of children vaccinated on time for pentavalent and measles
  • The proportion of children who have Pentavalent 1 and pentavalent 3 on time
  • The incidence of measles disease in young children using passive case detection
  • Utilisation of ANC, delivery and out-patient attendance for minor treatment
  • Costs and cost/effectiveness of the intervention

APPROACH

Study Site: The study is a randomized trial conducted in 8 local government areas randomly selected from the north, central and southern senatorial districts of Cross River State. Four LGAs namely Abi, Odukpani, Ogoja, and Calabar Municipality were randomized into the control arm while Etung, Biase, Obudu, and Ikom were randomized into the intervention arm.

The Intervention

The control LGAs had routine services while the intervention LGAs had routine services in addition to the trial interventions which are as follows:

  • TRL Training: Five training sessions were held with traditional and religious leaders in the intervention LGAs between May and November 2017. The sessions were on vaccines and vaccine preventable diseases, how vaccines work, influential leadership and communication approaches to promote vaccination uptake and roles of Ward Development Committees.
  • Community Engagement: In this component the trained community leaders educated members of the community during routine community meetings such as town council meetings, meetings of women, youth groups and religious meetings. The leaders shared information on routine vaccination, how vaccines work, and the need for caregivers to complete the vaccination schedule for their wards
  • Training of Health Workers: Training was held with health workers on root cause analysis, data summarization and presentation, and use of defaulters register to improve tracking of defaulters.
  • Strengthening of the WDCs: Six WDCs were revitalized.

Mid-term Data Collection

In February 2018 mid-term data evaluation was conducted in the 8 study sites using interviewer administered questionnaire. Data was also obtained on facility attendance, attendance at antenatal care, deliveries, measles, and neonatal tetanus for 2017 to monitor trend in uptake of services.

PRELIMINARY RESULTS

In total, the caregivers of 1268 children in the control LGAs and 1302 children in intervention LGAs were surveyed at midterm of the study.

Effects of the Intervention

  • The proportion of children aged 0 to 23 months who are fully vaccinated

Proportion of unvaccinated children dropped significantly from 8% to 2% in the intervention arm. However, there was no significant difference in up-to-date vaccinations between the intervention areas and controls.

  • The proportion of children vaccinated on time for Pentavalent and measles

Two percentage drop in proportion of children that received Penta 1 at 6 to 8 weeks in the control LGAs but 9% increase in the intervention LGAs was reported. Similarly there was a 1 percentage increase in timely measles vaccination in control with 10% increase in the intervention LGAs.

  • The proportion of children who have Pentavalent 1 and pentavalent 3 on time

More children received Penta 1 on schedule than they did for Penta 3 in both arms. The difference in timeliness between control and intervention at baseline and midterm were similar.

More children received Penta 1 on schedule than they did for Penta 3 in both arms. The difference in timeliness between control and intervention at baseline and midterm were similar.

The intervention arm showed a steeper drop at Penta 3 than the control arm. This may be due to the two strike actions during the study period.

  • The incidence of measles disease in young children using passive case detection

There seems to be an increasing trend in measles from 2014 to 2017. This may stem from the higher attendance in the facilities for care.  The reason for the observed increase will be explored further.

  • Utilisation of ANC, delivery and out-patient attendance for minor treatment

General attendance at facilities showed remarkable improvements including deliveries. Possible confounding factors need to be explored to determine to what extent the intervention may have contributed to it.

Community Involvement

  • In Obudu, a bridge was built by the community to improve immunization and provided housing for health workers
  • Community leaders in Etung now have a communal purse to sponsor the health workers to transport the vaccines from the local government store to the facilities. They have also instituted a day for vaccination for the 3 wards. Leaders are also visiting the health facilities.
  • Some communities provide volunteer health workers to support vaccination services.
  • Six WDCs were reactivated during the course of the Project.

CONCLUSION

  • The intervention may aid in the reduction of the proportion of unvaccinated children and timeliness of Penta 1 and measles. There is yet no evidence of the capacity of the intervention to increase the number of children with up-to-date vaccination.
  • The higher Penta 3 drop out in the intervention arm may be accounted for by strike action. Closure of facility and other health system weaknesses can negate the gains of the intervention.

 Research Team: This study is carried out by a research team from Effective Health Care Research Programme Nigeria in collaboration with the Swiss Tropical Institute as part of a grant from the International Initiative for Impact Evaluation (3ie).

REFERENCE
Ophori EA, Tula MY, Azih AV, Okojie R, Ikpo PE. Current trends of immunization in Nigeria: prospect and challenges. Tropical medicine and health. 2014;42(2):67-75.

WHO, 2015. Global Polio Eradication Initiative, May 2015 Info Sheet.

National Population Commission (NPC), Federal Republic of Nigeria and ICF International. 2014 Nigeria Demographic and Health Survey (NDHS) 2013. Abuja, Nigeria: NPC; and Rockville, MD: ICF International.