University of Calabar (Oku, Oyo-Ita); Norwegian Institute of Public Health (Glenton, Fretheim, Ames, Lewin); University of Oslo (Fretheim); Departamento de Saude, Nampula-Mozambique (Muloliwa); La Trobe University (Kaufman, Hill; Universidade Eduardo Mondlane (Cliff); International Union for Health Promotion and Education (Cartier); University of Ibadan (Owoaje); Swiss Tropical and Public Health Institute (Bosch-Capblanch); University of Basel (Bosch-Capblanch); Pontificia Universidad Catolica de Chile (Rada); South African Medical Research Council (Lewin)
"Communication about vaccination involves more than the message but is also influenced by the environment and the attitudes of the deliverer and receiver. It is pertinent for health policy makers and programme managers to understand these factors so as to effectively implement communication approaches."
This study, which forms part of the Communicate to Vaccinate (COMMVAC) project, aims to explore the perceptions and experiences of caregivers and health workers in Nigeria on vaccination communication strategies implemented in their settings. Only a quarter of eligible children in Nigeria receive all recommended vaccinations, perhaps due to factors such as: mothers' poor knowledge of immunisation, leading to low confidence and lack of trust; concerns about immunisation safety; long distances to and long waiting times at health facilities; and poor attitudes and skills of health workers. Some of these problems are linked to gaps in communicating vaccination information.
The researchers conducted the study between April and July 2014 in rural and urban settings in two States: Bauchi in Northern Nigeria and Cross River in the south. (In predominantly Muslim Bauchi, the diphtheria-tetanus-pertussis (DPT3) vaccination coverage rate is 12.5%, and vaccine refusal rates are higher; at the time of the study, Bauchi was one of the polio-prevalent States of Northern Nigeria. In contrast, predominantly Christian Cross State had higher DTP3 coverage rates (76.1%) and had remained polio-free for the previous decade.) The team carried out observations of communication activities (n = 40), in-depth interviews (n = 14) and focus group discussions (FGDs) (n = 12) amongst 14 purposively selected health workers, two community leaders, and 84 caregivers in the two states.
A synopsis of results:
- Caregivers' current sources of information regarding vaccination - Health workers at the health facilities were their main source of information regarding childhood vaccination during antenatal clinics. They reported that they also received vaccination information from the media (radio and television jingles, announcements). Caregivers in rural settings also commonly referred to town announcers, church announcements, sensitisation in markets, and home visits by health workers. A few caregivers mentioned that they heard about vaccination from older women in the community or from their friends and neighbours.
- Content of information in health education sessions received by/delivered to caregivers in vaccination clinics - All caregivers expressed that the messages received in the clinic were useful. In Cross River State, the health workers in the rural sites provided basic information on vaccination in the local language, and this information was usually reinforced just before campaigns. In both States, the urban facilities provided more detailed information compared to the rural sites, where facilities were often short-staffed.
- Caregivers' perceptions of communication in vaccination clinics - Some caregivers described barriers to receiving vaccination information: long waiting times, the clinic environment (e.g., stuffy and crowded, leading them to miss health talks), and health worker attitudes (a few caregivers described the impolite behaviour of health workers towards women with low levels of education, teenage mothers, and mothers who arrived late or forgot their vaccination cards. They explained that this behaviour could undermine trust in the health workers and could also discourage caregivers from listening to health education messages).
- Caregivers' preferences regarding information on childhood vaccination - In both states, a vast majority of urban caregivers reported that they preferred to receive vaccination information via text messages, including reminders of vaccination clinic appointments or upcoming campaigns. Most rural caregivers, on the other hand, wanted childhood vaccination information delivered to them through the town announcers. They suggested that town announcers should be engaged continuously to disseminate information, rather than during campaigns only. The media was a preferred means of communication for most rural and urban respondents in both states, but they stressed that the frequency of announcements and jingles targeted at childhood vaccination should be increased. The availability of several community radio stations in Bauchi, where the local language (Hausa) was used to deliver information, and poor power supply, made the radio (which could use batteries) more preferred among rural caregivers. Many caregivers in Bauchi and a few from Cross River were of the view that men should also be considered when delivering vaccination messages, because most women do not make decisions regarding their children without partner consent. Most rural caregivers suggested that vaccination messages and announcements should be delivered during news broadcasts because men mainly listened to the news, and that this should be done in the local language. Another suggestion was to deliver vaccination messages in mosques immediately after prayers to capture men's attention.
- Health workers' perceptions and experiences of factors affecting childhood vaccination communication - When delivering communication interventions, health workers described issues tied to poor interpersonal communication skills (due to lack of training), poor motivation (due in part to poor remuneration in relation to the risks involved), and attitudes of community members, including vaccine resistance. Some reasons cited as contributing to resistance included: misconceptions and rumours linked to religious beliefs, scepticism surrounding the polio vaccine, and the perceived marginalisation of hard-to-reach communities. One health worker from Bauchi described how vaccine refusals were more common in the context of polio campaigns; house visits during campaigns were viewed with more suspicion than vaccines delivered at clinics. This problem was sometimes addressed using community dialogues involving relevant community stakeholders, most often religious or traditional leaders.
- Comparing health workers' and caregivers' views on useful channels for vaccination communication - see Table 2.
Among other things, this study revealed that vaccination information was generally sparse in the two settings, with urban settings generally having more detailed vaccination related information compared to rural settings. This has serious implications, with majority of the population residing in rural communities, a sector that is usually underserved. The study also noted that poor attitudes of health workers towards caregivers as well as poor motivation of health workers could be linked to deficient communication skills among health workers.
Caregivers perceived the clinic environment to influence communication. To help ensure the attention of the caregiver, the health care system needs to make sure the clinic environment is conducive to communication activities. This includes addressing some basic issues like providing sufficient seats and ensuring good ventilation, and reasonable waiting times. When the physical environment of the clinic is ignored, it can reduce the attention of the caregiver and act as a barrier to effective communication between the health provider and the caregiver.
According to the researchers, "[s]everal opportunities exist to leverage on the polio footprint to strengthen routine immunization communication. The use of credible communication sources found to be useful and acceptable within the community, such as engagement of traditional and religious leaders in routine immunization programmes, could ensure sustained demand for vaccination services within their communities. Town announcers engaged to provide information to the community during campaigns could be engaged to actively remind community members where and when routine immunisation services are being provided along with simple key messages. These channels would enhance community ownership and be more sustainable in the long run. However, polio campaigns, as seen in most vertical programmes, had little effect on routine programmes, as most resources were used for campaign-related activities."
In conclusion, they suggest that "a 'blanket' approach to delivering vaccination communication is not what people want or need rather communication channels needs to be tailored by setting and recipient. This will require strategic planning of communication messages, creating a conducive environment for communication, addressing issues to enhance the relationship between caregivers and health workers, and paying attention to preferred channels of communication by caregivers and health workers in local, regional and national settings."
PLoS ONE 12(11): e0186733. https://doi.org/10.1371/journal.pone.0186733 Image credit: Galaxy TV