HPI Institute (McArthur-Lloyd, McKenzie); Mailman School of Public Health, Columbia University Medical Center (Findley); Health Partners International (Green); Women for Health (Adamu)
"The transition plan for the Polio Eradication Initiative in Nigeria must give a prominent role to community volunteers. They have and will continue to have a major influence on supporting routine immunization and maintaining trust of the primary health care system at community level."
This paper explores the community engagement (CE) component of the Partnership for Reviving Routine Immunization in Northern Nigeria; Maternal, Newborn, and Child Health Initiative (PRRINN-MNCH), suggesting that the lessons learned from this project are relevant to the Polio Eradication Initiative (PEI) when Nigeria reaches polio-free status and community mobilisers are mainstreamed into routine health services.
As explained here, Northern Nigeria has a history of low use of health services, resistance to immunisation programmes, and high maternal and child mortality rates. Northern Nigeria's environment consists of extreme poverty, low literacy, few skilled health workers, and community resistance to immunisation and government services. Cultural, physical, and financial barriers prevent many families from accessing health care. Funded by the United Kingdom (UK) Department of International Development (DFID) and the Norwegian government, PRRINN-MNCH ran from 2006 to 2014, drawing on an integrated approach to strengthen health services and increase community demand for and access to quality health care. PRRINN-MNCH activities were closely monitored using population-based random household surveys conducted in 2009, 2011, and 2013. Results measured the progress of maternal, infant, and under-5 mortality within project emergency obstetric care clusters and the effect of CE activities.
The project's CE approach aimed to empower communities, work with volunteers, and develop solutions to overcome barriers to health. The PRRINN-MNCH approach balanced addressing social factors and other demand-side constraints behind the low use of health services. PRRINN-MNCH mapped a theory of change to identify barriers and activities to achieve short-, medium- and long-term behaviour change. The theory of change was based on 3 principles:
- Generate communitywide social approval for behaviour change in Northern Nigeria - Traditional social structures and institutions exert considerable influence over individuals; therefore, community members needed the support and approval of community leaders, family members, and peers to adopt new behaviours. Social approval also involved reaching out to key decision makers and opinion leaders, including husbands, mothers-in-law, sisters-in-law, traditional community leaders, and religious leaders.
- Adopt a whole-community approach - In the project states (Jigawa, Katsina, Yobe, and Zamfara), child deaths were found to be concentrated among a relatively small proportion of households (80% of child deaths occurred in 20% of the women in economically poor, rural communities in Jigawa, Yobe, and Zamfara), where women perceive that they lack social support and who have no access to information and services. CE activities addressed the importance of social inclusion and activities were tailored to specifically reach undersupported women as part of the whole-community approach.
- Build community capacity and cohesion for long-term ownership and sustainability - The community leads and eventually sustains the behaviour change process, ensuring that appropriate MNCH health-seeking behaviour become the norm.
Application of these principles led to the following CE programme components, in which community ownership was deemed essential:
- Holding an initial community forum to encourage people to reflect on their health situation and commit to improvements and practical solutions. Recruiting and training community volunteers to facilitate a process of change at community level. Thirty community volunteers were identified at this forum and were trained on 12 MNCH and routine immunisation (RI) modules and interpersonal communication (IPC). All community volunteers recorded their activities, which were shared with local government area (LGA) officials to monitor, review progress, and understand community concerns and needs.
- Arranging community discussion groups, facilitated by community volunteers, to give community members an opportunity to reflect on the local MNCH situation and to plan how they should respond. Everyone in the community was encouraged to participate. Many communities held separate groups for men and women. The discussions began by focusing on maternal emergencies, which are frequent and an urgent concern in most Northern Nigerian communities. Proactive steps were taken to include the youngest and/or economically poorest women and those who may be socially excluded. Discussions allowed the community to debate, contextualise new health information, and decide on and participate in solutions. By including the whole community, all key members were able to learn and share new knowledge with their spouses, family, and friends, facilitating adoption of healthier behaviours or actions.
- Engaging traditional, religious, and community leaders - before any activity was conducted - to participate in and support the change process. Being important sources of information in Northern Nigeria, religious leaders were also trained by the project to deliver key MNCH messages.
- Building community-based service delivery, led by trained community health workers who go door-to-door to provide health information and basic MNCH services.
- Strengthening community oversight of their primary health care centre and establishing facility health committees.
- Using targeted activities to engage and support the most vulnerable (e.g., through young women's support groups).
- Establishing community emergency response systems, including free emergency transport services for women in labour, blood donor groups, and savings to support emergency health costs.
- Supporting mentoring and coaching by officials from the state and LGA to help communities translate their new knowledge into action.
- Using community-led monitoring to show the results of CE activities.
In terms of particular types of communication strategies, community volunteers used Say and Do interactive communications and narrative mimes to help participants remember key health messages. With Say and Do, community volunteers and participants said the information to be learned and then did an action using their body to help remember the information. An example was the immunisation hand, where the immunisation schedule was said and also demonstrated using fingers to represent the timing of each dose. Narrative mimes were short dramas where the community volunteer read a short story, which was then acted out by the participants. The drama was followed by a community volunteer–led discussion to encourage learning and sharing of messages. Community volunteers also led discussions following the "Majigi" (a mobile cinema) on the importance of preventing polio. The community volunteer work was coordinated with the development and dissemination of radio jingles conveying immunisation and MNCH promotion messages throughout the states. Radio is frequently used in Northern Nigeria as a communication tool, and the project found that jingles were more effective when combined with community discussions.
The PRRINN-MNCH strategy was rolled out in phases to ensure that health services were available to meet community needs. The integrated package was spread progressively from 2009 to 2014 until it covered clusters in 72 LGAs in the 4 states, with a combined population of 14.7 million people. Community volunteers trained by the programme reached a population of 3 million by working in their own communities. A much larger population was reached (7.64 million) when the community volunteers rolled out their support to neighbouring communities. By the end of the programme, the CE component had recruited and trained 30,840 community volunteers, averaging around 30 per community. They spent 2–3 hours per week on CE activities and because the work was flexible, they were able to fit volunteer work around their regular household and farm responsibilities. In fact, focus groups discussions (FGDs) with community volunteers showed a strong sense of community and religious obligation. They knew they would receive no financial incentives, but they were motivated by seeing health changes and knowing that they were making a difference in their community. The volunteers said they felt rewarded by helping save lives.
Baseline and endline population-based random household surveys conducted in 2009 and 2013 showed improved community knowledge, increased use of antenatal care and immunisation services, and a decrease in maternal, infant, and under-5 mortality. For example, the effect of the discussion groups led by community volunteers can be seen in the large increase in the proportion of women's knowing of maternal danger signs, from 16.8% to 52.3%, and in the proportion of women with children under 2 years of age who knew the number of RI visits, which increased from 57.3% to 82.7%. From 2009 to 2013, women receiving antenatal care increased from 25% to 51%, and the use of skilled birth attendants increased from 11% to 27%. Women who participated in community dialogue or group discussions were more likely to use antenatal care services. Data show that women were using facilities, and CE activities were helping to overcome barriers. The proportion of women with standing permission to take a child to a health facility increased from 42.7% to 86.3%, showing that husbands and other family decision makers shifted their behaviour to give higher priority to support women's and children’s health. In the project areas, the maternal mortality ratio fell from 1,270 to 1,057; under-5 mortality decreased from 160 to 90.1 per 1,000 live births; and infant mortality decreased from 90 to 46.9 per 1,000 live births. The overall coverage of fully immunised children rose from 2.2% to 19.3%. "The rise in the fully immunized child coverage rate is unlikely to be the result of Polio Eradication Initiative campaign activities. To be fully immunized, a child must receive the Baccille Calmette Guérin (BCG) vaccine - which is not given during supplementary immunization activities..."
In 2014, Taylor and Findley (2014) analysed the 2013 endline data and conducted FDGs and interviews in Katsina and Zamfara to further assess and compare the effect of the different levels of exposure to the CE approach against the theory of change. The following were the key findings:
- Providing quality services and improving the relation between the community and health workers improved use of services. Facility health committees improved linkages between the health system and communities, resulting in more responsive services.
- Community health workers and female skilled birth attendants were influential and increased retention of information and health-seeking behaviour through home visits, health facility talks, consultations including antenatal care, and provision of respectful maternity care services.
- Involving men, community elders, and religious and traditional leaders in the CE activities was important. When respected or influential men spread health messages, it enabled social approval and encouraged use of services.
- Several sources of information (media, religious leaders, informal networks) helped communities retain messages and change their behaviour. Information alone did not have a strong impact on behaviour change, but integration with CE activities helped to spread and reinforce information.
- Complete CE communities and those with the longest exposure to CE had increased ownership and support for emergency transport services, community volunteers, and community members, showing the long-term possibilities for sustainability.
- Young women's support groups and home visits by community volunteers or community health workers helped to reach socially excluded and undersupported young women. The young women in these groups knew more and were more likely to use key services than those outside the groups.
According to the report, state and LGAs, as well as community leaders and members, were involved in PRRINN-MNCH activities, helping to ensure collaboration, funding, and sustainability of activities. "The establishment of these relations was essential to reaching government and project objectives." However, the project faced certain constraints and challenges, such as ensuring long-term government and community commitment. "Timing is crucial and a transition strategy for CE must be developed soon to allow for necessary government buy-in and process and to ensure that the Polio Eradication Initiative community experience can be expanded to address short-term health needs and long-term behavior change in Northern Nigeria." The following recommendations can provide guidance on how to transition polio community mobilisers to further improve RI and health outcomes in the Northern states:
- Ensure strong supply side interventions. For example, the introduction of inactivated polio vaccine (IPV) into routine services is an opportunity to refocus on RI and make improvements in vaccine distribution, cold chain strengthening, and health worker training.
- Work with state and LGA governments to identify, plan, and budget activities, including CE interventions. State and local government areas need to integrate comprehensive demand-side health interventions into their programming. This must incorporate activities that address all demand-side barriers simultaneously, including receiving feedback and recommendations from communities.
- Develop a whole community approach with intensified activities. The 2014 PRRINN-MNCH evaluation showed that when CE activities were well coordinated and intense, there was greater likelihood of longer term change in health behaviours.
- Expand scope of PEI community mobilisers. With additional training on the PRRINN-MNCH CE techniques and content, they can facilitate community discussions and work with their communities to identify and address barriers to RI and MNCH. They could also be trained on the social factors affecting health and service access. PEI mobilisers are already involved in monitoring and collecting data; engaging them in a community monitoring system would help to strengthen data collection and management.
- Reduce time commitment/increase flexibility. The PRRINN-MNCH volunteer programme was flexible and had a small time commitment; this approach could be adopted for converting the polio mobilisers to community volunteers.
- Revisit incentives. Whereas the PEI community mobilisers have received financial incentives for their participation, PRRINN-MNCH volunteers received no stipend for their work but were motivated by training, the ability to help others, and the fulfillment of religious obligations. In the interest of sustainability, it may be necessary to gradually reduce the incentives received for community work, while at the same time promoting the nonmonetary rewards and emphasising the important role mobilisers have played in eliminating polio.
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, 2:1, 1-10, DOI: 10.1080/23762004.2016.1205887. Image credit: PRRINN-MNCH.