London School of Hygiene & Tropical Medicine, or LSHTM (Chantler, Karafillakis, Sile, Larson); Assosa Referral Hospital (Wodajo); International Rescue Committee, or IRC (Demissie, Mohammed, Olorunsaiye, Landegger)
"These findings demonstrate the benefits, challenges and nuances involved in promoting shared community responsibility for immunization."
Increased attention is being paid to the role of community engagement (CE) strategies in improving demand for immunisation. The International Rescue Committee (IRC) developed a multi-pronged CE strategy (the Fifth Child Project, or FCP) in an effort to close the immunisation gap in Benishangul Gumuz Regional State (BGRS) in north-west Ethiopia, where the third dose of pentavalent vaccine (diphtheria, tetanus, pertussis, Haemophilus influenza type B, hepatitis B) was only 41.7% in 2011. This paper reports qualitative findings from a formative evaluation of the FCP's CE strategy and related tools.
With regard to immunisation programmes and CE, cited in the paper are Sabarwal et al., who stress the importance of the health system working directly with service beneficiaries (e.g., community members) to address supply and demand side factors; it is not enough for an intervention to be community-based, it must also actively involve community members. In order for CE to be useful and transformative, there needs to be transparency about how responsibility and power will be shared.
IRC developed and implemented the FCP in 114 kebeles (smallest administrative unit in Ethiopia) in Assosa and Bambasi woredas (districts) in BGRS between 2014-2017. The FCP and related tools were designed in consultation with the Regional Health Bureau, Woreda Health Officers (WoHO), and community leaders. IRC continuously monitored the progress of the FCP and iteratively refined it until 2017. The FCP was integrated within the health extension programme (HEP) launched in BGRS by the Ethiopian Ministry of Health in 2009.
The FCP consisted of 2 tools and a CE strategy:
- The vaccine defaulter-tracing tool (DTT) was a simple carbon-copy registration form used at the health post to record, by village, basic infant/caregiver information and vaccines missed. Its use helped health extension workers (HEWs), who are young women selected by their communities to be trained to provide primary health services at health posts, and Health Development Army leaders (HDALs) identify homes that HDAs, which consist of female volunteers supervised by HEWs, should visit/follow-up.
- A colour-coded health calendar, called Enat Mastawesha (Amharic for "mother's reminder"). Pregnant women and women with infants received the Enat Mastawesha from HEWs and HDAs. The calendar included coloured stickers that HEWs attached to a mother's perinatal and an infant's immunisation appointment dates. It also portrayed key health messages in pictorial format, e.g., when to seek medical assistance urgently during pregnancy.
- The CE strategy consisted of training HEWs and HDAs in using the tools, strengthening their interpersonal communication (IPC) skills, and promoting shared responsibility for immunisation at household and kebele command post level, with the aim of leveraging improved follow-up of unimmunided infants and timely uptake of scheduled vaccines. To ensure that immunisation services were available and timely, additional systems support was also provided.
IRC hypothesised that the use of the DTT and calendar within a larger CE strategy - that directly involves caregivers and specifically implicates existing community leadership structures - would address identified barriers to vaccine uptake. They joined with the London School of Hygiene & Tropical Medicine (LSHTM) to conduct a formative evaluation of the FCP, focusing on the project integration into the health system, utilisation and acceptability, community co-management, and contribution to improving routine immunisation system performance. Routine immunisation data from 2 districts was analysed; and a series of interviews, focus group discussions (FGDs), and observations of project activities were conducted in 3 kebeles within these districts from May-July 2016. Specifically, a total of 46 interviews, 6 FGDs (3 with HDAs and 3 with caregivers, including 2 with mothers and 1 with fathers), 15 observations of routine visits by HEWs and HDAs to caregivers (5 per kebele), and 3 command post meetings observations (1 per kebele) were conducted from May-July 2016. In addition, 5 interviews and 2 FGDs were conducted as part of a data-verification exercise in November 2016.
Overall, the evaluation found that the FCP introduced new ways of working that helped health workers identify and connect with hard-to-reach families. Summary of main results by analytical theme:
- Community acceptance of the FCP - Kebele leaders and HEWs reported that some community members were initially suspicious of the FCP thinking that, "the government was forcing them to do something that was not in their interest." (KL, #45) These concerns were addressed in orientation meetings with kebele leaders, which were crucial for community acceptance of the FCP.
- Enat Mastawesha: catalyst for health dialogue within homes - The calendar was described by all types of interviewees as an excellent personalised reminder for mothers that had reduced health workers' workload, increased demand for immunisation, and facilitated timely uptake of vaccines. It was attached to walls in caregivers' homes and served as a communication aide for health workers and a catalyst for health-related discussions between family members. Most caregivers stated that mothers and fathers were involved in vaccine decision-making and, where possible, HEWs would explain the calendar to both. Caregivers (some of whom were illiterate) liked the fact that the calendar included pictures and found the stickers useful.
- Shared community responsibility for immunisation - HEWs stated that the defaulter tracing system and the related DTT had improved their access to vaccination data and enabled them to count and identify defaulters in a more systematic manner. Similarly, WoHOs valued the system as an information source that facilitated collaboration with KLs. Pre-existing accountability mechanisms facilitated the community co-management of the FCP. There was evidence of community-agreed sanctions (monetary fines and cautions by local court) for non-compliance with the infant vaccination schedule; in general, the threat of sanctions served as a deterrent, a last resort for persistent non-immunisers. The establishment of community-agreed sanctions, which were not part of the FCP, is evidence of community ownership (though these sanctions did raise ethical questions).
- Demand for and access to immunisation - Many interviewees reported a shift in public opinion about immunisation over the past 5-8 years: from reluctance to high levels of vaccine acceptance. In gauging the specific role played by the FCP in this change of attitude, health workers highlighted the personalised interactions it facilitated. Interviewees were keen for the FCP to expand but also stressed the need to address remaining infrastructural barriers.
- Health system integration - WoHOs reported that the FCP became a valuable and integral part of the existing HEP. KLs and other health workers agreed that the project had created systematic ways of encouraging the uptake of immunisation in their communities. The FCP was well adapted to the health infrastructure.
These findings highlight the fact that, through the FCP, the follow-up of unimmunised children became more personalised, and the Enat Mastawesha stimulated health discussions between mothers and fathers within homes as well as between health workers and families. It promoted joint parental responsibility for vaccine decision-making, and health workers were able to address parents' questions more specifically within the home environment. "Core to this is two-way communication."
Although this is a formative evaluation and results cannot be attributed to the intervention, an analysis of routine immunisation data shows that between January 2013 and December 2016, pentavalent-3 coverage increased from 63-84% in Assosa, and from 78-93% in Bambasi. The increase in vaccination coverage in both woredas was statistically significant.
In conclusion: "The intervention was successful at promoting parental responsibility for vaccination but may have contributed to kebeles creating and agreeing on their own sanctions against non-vaccinated individuals. These findings point to the need for more transparency around community self-regulatory measures in future immunization programs. Involving communities and relevant leaders in immunization programs can be very effective, however the lines of responsibility and the authority to determine and execute different measures needs to be clarified to ensure that such measures are in line with national health policy and do not deter underserved families from vaccinating their children."
International Journal of Environmental Research and Public Health 2018, 15, 667; and The Vaccine Confidence Project website, April 4 2018. Image caption/credit: A HDA member explaining the calendar to a caregiver. (Photo by Anna Kim, IRC) Video credit: IRC