Rabia Sadat
Abu Mohd Naser
Publication Date
July 13, 2016

United Nations Children's Emergency Fund, or UNICEF (Sadat); Rollins School of Public Health (Naser)

"The success of any community health awareness interventions including polio eradication programs largely depends on health workers having appropriate knowledge and skills, and on their quality delivery of health messages."

Although involving the volunteer communication mobilisers (VCMs) was arguably one of the significant interventions for polio eradication in Nigeria, limited data are available on VCM performance. To fill this gap, researchers conducted a study to (ii) assess and compare the knowledge, job-related characteristics, and performance of VCMs in two Local Government Areas (LGAs) of Kano state, which is one of the 11 states in northern Nigeria where religious propaganda to boycott oral polio vaccination (OPV) occurred, (ii) assess whether VCMs' knowledge and job-related characteristics were associated with performance, defined as the number of key health messages delivered during last household visit and implementation of community visits as performance variables of VCMs. (According to the researchers, a more appropriate performance measure would have been the total number of children vaccinated in each of the VCMs' catchment areas, but the current reporting system of immunisation does not capture this information.)

As a response to the fact that, in 2012, more than 50% of the polio cases occurred in Nigeria, the Global Polio Eradication Initiative (GPEI) deployed VCMs to increase community awareness for polio vaccination in that country. Initially, 613 VCMs were selected from their immediate communities and deployed in the Kano, Kebbi, and Sokoto states to identify, characterise, and enlist chronically missed children using community-friendly approaches such as house-to-house visits among noncompliant families in the resistant areas. Each VCM was involved in mobilising 200 to 250 families for health education (using flipcharts to engage caregivers with behaviour-changing dialogue) on polio and routine immunisation (RI), maternal and child health, malaria, and personal hygiene. All the VCMs received polio training and all were equipped with logistical and promotional materials such as a register books, flip charts, and hizabs for delivering health messages. (Hizab, a head cover used even by the non-Muslim VCMs, is both the mandatory dress code for VCMs and functions as a form of community identification and recognition. "Nevertheless, we identified that only a small proportion of the VCMs reported wearing the hizab.") After their involvement, the number of polio cases, the proportion of missed children and the proportion of non-compliance families decreased in some LGAs. In subsequent years, a number of new VCMs were added to the already-recruited pool in the low-coverage areas. Three years after the introduction of these initiatives, the World Health Organization (WHO) declared Nigeria a polio non-endemic country on September 25 2015.

To understand whether VCMs' knowledge and job-related characteristics were associated with performance, researchers conducted a cross-sectional survey in Nassarawa and Ungogo from June through October 2014. VCMs in both LGAs received a similar type of training and supplies. The researchers asked VCMs about the consequences of polio, preventive strategies, and health communication messages to assess knowledge. They considered VCMs' performance satisfactory if they delivered more messages during their last visit, and knew the number of and knew the number of under-5 children and neonates in their settlement. They used t-tests to compare continuous and chi-square tests for categorical variables, and ran linear and ordinal logistic regression to understand if knowledge and job-related characteristics were associated with performance.

All of the VCMs were female. Of the VCMs, 69% (118/170) were enrolled from Ungogo. The researchers found that 63% of VCMs in Nassarawa had appropriate levels of knowledge about health education messages, compared to 26.3% in Ungogo (p < .001). They also found that 32.7% of VCMs in Nassrawa and 15.3% of VCMs in Ungogo mentioned that polio vaccination protects children from paralysis (p = .040). Among VCMs, 75% in Nassrawa and 31% in Ungogo knew the total number of under-5 children in their catchment area of work (p = .001). They found that, for every 10 additional months of experience, VCMs delivered 1.3 more messages during household visits (95% confidence interval (CI), 0.56–1.9, p = .001). VCMs who knew that polio causes paralysis delivered 0.5 more health messages than VCMs who did not have that knowledge (95% CI, 0.08–2.3, p = .018). "We associated better performance of the VCMs with their delivery of a high number of key messages in their last household visit because it has been demonstrated that families pay more attention to polio vaccination when VCMs also talk about other key household practices..."

In short, the results demonstrated that VCMs' polio-related knowledge was associated with health message delivery performance. The following excerpt from the Discussion section of the paper explores additional aspects and implications of the findings:

"Our analysis identified a low level of knowledge about the consequences of the polio virus among the VCMs of both LGAs, despite having polio training. Three out of four VCMs in Nassarawa and half of the VCMs in Ungogo did not report that polio causes paralysis. This demonstrates that VCMs were not aware of the irreversible and incurable crippling sequelae of polio. The health belief model suggests that preventive measures are adopted when the negative health outcome is perceived as serious (Janz & Becker, 1984). With this in mind, such lack of knowledge among the frontline workers may be seen to present challenges for community-level demand and attitudes about vaccination. Nevertheless, a high proportion of VCMs from Nassarawa had accurate preventive knowledge for polio. Almost all VCMs in Nassrawa and three-fourth VCMs in Ungogo reported that polio can be prevented by vaccination. Moreover, a higher proportion of VCMs from Nassarawa reported delivering accurate health messages during household visits, such as all under 5 children, regardless of age, sex, illness, and sleep status need to be vaccinated, and that the polio vaccination can protect the child from paralysis. These health messages help mothers and caregivers recognize the value of the vaccines, and coverage is likely to be higher when caregivers know its purpose...

We also identified that a higher proportion of VCMs in Nassarawa knew the actual number of under 5 children and newborns in the settlement, suggesting that they were better informed about their responsibilities in their settlements. VCMs' polio prevention and appropriate health education messages were also consistent with the higher vaccination coverage in Nassarawa than Ungogo, as reflected in the LQAS [lot quality assurance sampling] data. In the four months between January and April 2014, Nassarawa had greater than 90% vaccination coverage compared to 80-90% coverage in Ungogo between February and April 2014. This suggests a performance gap in the communication campaign in Ungogo, requiring in-process monitoring. The knowledge gap of the VCMs in Ungogo may underlie the lower vaccination coverage in that LGA.

...Our findings indicate that authorities in Ungogo need to focus on increasing the knowledge of existing VCMs....Although all low-performance problem[s] cannot be solved by providing training solely, it does need to be considered as the first step of improving low performance when knowledge level is low....Supportive supervision may also increase the knowledge and skills of the health workers.

We identified several factors that determined the individual-level performance of VCMs. Experienced VCMs delivered more health education messages during household visits. Perhaps their motivation for work is due to several factors, including social recognition and improved interpersonal skills, that increased with their increased work experience (Gopalan, Mohanty, & Das, 2012). We identified that less-experienced VCMs delivered fewer health messages regardless of whether they worked in the morning or afternoon. Nevertheless, experienced VCMs who worked in the afternoon delivered more messages compared to experienced VCMs who worked in the morning. A number of factors from both caregivers' and VCMs' sides may have contributed to this: caregivers were likely to be busier with household chores in the morning such as preparing food and readying children for school. This may have resulted in them having less time to hear VCMs' messages. Given that most of the VCMs were homemakers with an average of five children in their households, VCMs' morning work might also have been more hurried and may have led to them delivering fewer messages...

Workload plays an important role in the quality and productivity of VCMs work. Although VCMs in Nassrawa had more knowledge, they had an increased workload compared to VCMs' in Ungogo. They covered 1.6 times more children under 5, and 1.4 times more newborns in their catchment areas than the VCMs in Ungogo. To compensate for this increased workload, VCMs in Nassrawa spent considerably less time during each household visit, although their average working hours per day were more than the VCMs from Ungogo....If there are more households in the catchment area per VCM, there is a greater need to recruit more VCMs in the LGA..."

Editor's note: This paper has been published as part of a United States Agency for International Development (USAID)-funded initiative to increase the number of peer-reviewed papers on routine and polio communication and to ensure that academics from a range of countries, including those facing the greatest polio and routine immunisation challenges, are supported in getting their research peer reviewed, published, and widely disseminated through The CI and the new journal Global Health Communication.


Global Health Communication, 1:1, 48-57, DOI: 10.1080/23762004.2016.1199939. Image credit: UNICEF