Assessment of Unmet Needs to Address Noncompliant Households during Polio Supplemental Immunization Activities in Kaduna State, 2014-2016

"There was an increase in OPV uptake among caregivers and a reduction in the number of noncompliant households recorded in Kaduna state as a result of fulfilling their unmet needs."

Vaccine rejection by caregivers persists in some parts of northern Nigeria, which compromises the quality of supplemental immunisation activities (SIAs) designed to ensure uptake of the oral polio vaccine (OPV). Kaduna state remains at high risk due to persistent pockets of noncompliant households and missed children during monitoring exercises that follow SIAs. Conducted in 13 high-risk local government areas (LGAs) in Kaduna state, this study assessed the impact of one strategy for improving the quality of SIAs - the use of unmet needs data - as it was applied in each round, from 2014 to 2016, to gain insight into the reasons for the caregiver to be noncompliant.

Designed by the World Health Organization (WHO) country office in Nigeria, the unmet needs tool is a questionnaire that assesses: the extent of resolution or persistence of noncompliant households; knowledge gaps for caregivers on the immunisation process; the preferred credible source of information for caregivers on immunisation; the persons whom they would trust to convince them to provide full immunisation for their children; and the readiness of caregivers to support immunisation in their communities and ways to provide such support in their immediate environment. The findings provide insight on how to mitigate the misperceptions caregivers have towards immunisation, while also shedding light on pressing issues aside from polio vaccination that can be tackled to improve the uptake of other healthcare interventions.

The researchers analysed 2 datasets: the unmet needs data collated from noncompliant communities from 2014 to 2016 in the 21 rounds of SIAs conducted in Kaduna state, and noncompliance data recorded in the state from 2013 to 2016. WHO staff trained field volunteers (FVs) on how to apply the unmet needs tool. A total of 50 households from 5 settlements in each of the 13 high-risk LGAs were considered for the unmet needs intervention during each SIA round. Ten households per noncompliant community in the 5 selected settlements were randomly visited and given the unmet needs questionnaire. Questionnaires were collated after each round to direct specific innovations to different noncompliant communities to increase the uptake of OPV in next coming SIA round. Overall, a total of 12,120 households were visited in 129 of the 255 political wards of the state (more than 50%) between 2014 and 2016. In addition, tally sheet data were collated after each SIA round to compile the total number of noncompliant households and children involved for each LGA by settlement.

Respondents interviewed were from 1,405 noncompliant settlements in the 13 high-risk LGAs. The majority of the caregivers who took part in the study are from a low socioeconomic class, with poor literacy levels, who lack basic amenities such as potable water, electricity, and infrastructure and who have limited access to affordable medical care.

The immunisation knowledge gaps of caregivers showed that 3,107 (27%) wanted to know why so many SIA rounds are conducted in Kaduna state. A total of 2,508 (22%) and 831 (7%) of respondents were concerned about OPV safety and the benefits of OPV, respectively, and want the programme implementers to shed more light on these. A total of 2,318 (20%) caregivers want to know why only OPV is given on a regular basis before they will allow their children to get vaccinated. Also, 1,051 (9%) and 226 (2%) were worried about possible side effects and risk of paralysis associated with regular use of OPV, respectively.

A total of 3,290 (28%) caregivers prefer to be mobilised by religious leaders for vaccination, 2,633 (23%) by qualified health workers, and 1,781 (15%) and 1,316 (11%) by traditional leaders and community leaders, respectively. Political leaders, relatives, or others were found to have roles in mobilising 697 (6%) noncompliant caregivers each, while mobilisation percentages through mass media and town announcers were 2% each.

The suggestions made by caregivers for added interventions alongside immunisation that would have made them fully immunise their children were free medical consultations in 2,904 (25%) and discounted drugs in 2,284 (20%). Others (e.g., electricity, food, and fertilizer) were mentioned by 1,588 (14%), and antimalarials were mentioned by 1,355 (12%) caregivers. Insecticide-treated nets (ITNs), hospital care, and antenatal care (ANC) accounted for 891 (8%) each. The majority of caregivers felt that polio is not a priority because these basic needs have not been met by the government.

Overall, in 2016, the majority of the parents (6,304 (54%) of 11,616) responded positively to supporting immunisation services in their communities. Of these, 3,379 (54%) were ready to vaccinate their children publicly. A total of 1,525 (24%) were prepared to sensitise other noncompliant families. Furthermore, 1,399 (22%) respondents were ready to convince neighbours, family members, and others to accept vaccination for their children.

The trend of identified noncompliant households documented during SIAs in Kaduna state from 2014 to 2016 showed a steady decline in the trend, especially in the data observed in 2015-2016. The number of noncompliant households reduced over time by 79% from 16,331 in September 2013 to 3,394 in May 2016.

The study's finding that there were very few caregivers who requested other routine immunisation (RI) antigens indicates a low demand for RI (probably due to lack of adequate understanding of the importance of RI antigens). The researchers urge stakeholders to work to create demand in the context of RI services so as to prevent vaccine-preventable diseases from causing outbreaks in high-risk communities.

The researchers assert that the unmet needs tool was successful because the data generated helped identify and address problems peculiar to noncompliant communities and interventions such as sensitisation and community dialogue meetings with noncompliant caregivers on the benefits of OPV and the reasons for "too many rounds" of OPV campaigns. Also directed to noncompliant communities based on the identified unmet needs of the caregivers were: provision of free medical consultations and free discounted drugs; the engagement of religious leaders, traditional leaders, and youth; and edutainment programmes. Furthermore, the unmet needs intervention was effective in changing the negative attitude of some parents on polio immunisation programmes, with a majority willing to support immunisation in their communities.

Furthermore, noncompliant communities in the state informed the researchers of the need for a holistic approach. Policymakers need to collaborate with other units in the healthcare service delivery system and also with other sectors, especially areas that affect the general well-being of the populace that have a direct or indirect bearing on health determinants. Factors affecting health determinants are the provision of portable water, power supply, and good infrastructure. The majority of respondents in the study felt they had been deprived of such amenities by the government and craved these services before they could allow vaccination of their children.

In conclusion, outcomes from the analyses of unmet needs data were used to direct specific interventions to certain areas, which was an effective strategy for reducing the number of noncompliant households recorded during SIA rounds in Kaduna State. Hence, the unmet needs intervention approach could be adapted at all levels to address challenges faced in other primary healthcare programmes in Nigeria.