Communication Strategies to Promote the Uptake of Childhood Vaccination in Nigeria: A Systematic Map

"Effective communication is a critical component in ensuring that children are fully vaccinated. Although numerous communication interventions have been proposed and implemented in various parts of Nigeria, the range of communication strategies used has not yet been mapped systematically."

This study forms part of the Communicate to Vaccinate (COMMVAC) project, an international initiative aimed at building research evidence for improving communication with parents and communities about childhood vaccinations in low- and middle-income countries. (See Related Summaries, below.) Its aims are to: 1) identify the communication strategies used in both rural and urban settings in Bauchi State in Northern Nigeria and Cross River State in Southern Nigeria; 2) map these strategies against the existing COMMVAC taxonomy, a global taxonomy of vaccination communication interventions; 3) create a specific Nigerian country map of interventions organised by purpose and target; and 4) analyse gaps between the COMMVAC taxonomy and the Nigerian map. To do this, the researchers identified vaccination communication interventions through interviews carried out from January to June 2014 among purposively selected stakeholders in the health services and relevant agencies involved in vaccination information delivery. They also conducted observations and document review.

Nigeria has one of the highest rates of under-5 mortality in the world, and vaccine-preventable diseases account for approximately 22% of child deaths in the country. To cite an example: the Diphtheria, Pertusis, Tetanus third dose (DPT3) coverage rate in one of the study sites, Bauchi, is 12.5% (in contrast, the coverage of DPT3 in the other study cite, Cross River, is 76.1%). Low vaccination rates have been attributed partly to vaccine hesitancy, a behaviour influenced by factors including a lack of trust in the vaccine or the provider, people not perceiving a need for or not valuing the vaccine, poor access, lack of knowledge, rumours, religious beliefs, illiteracy, and other social and political factors. With the hope of addressing some of these issues, the country's National Social Mobilisation Working Group, headed by the United Nations Children's Fund (UNICEF), develops and coordinates communication strategies for all childhood vaccinations. At state and local levels, social mobilisation committees coordinate these activities, which tend to focus on advocacy, social mobilisation, and behavioural change communication.

The COMMVAC taxonomy was developed in response to the lack of a comprehensive approach to identifying and organising communication strategies or interventions used to improve childhood vaccination uptake (see Table 2 in the document and Related Summaries). The taxonomy illustrates the relationships between different types of communication interventions and clarifies the key purposes and features of interventions to aid implementation and evaluation. A complete map of vaccination communication interventions for each state, organised by purpose, is available as a Supplementary table (Appendices 1 and 2). Table 3 provides examples of the interventions identified in each taxonomy category, such as training in Bauchi State of volunteer community mobilisers and traditional and religious leaders to negotiate with non-compliant parents and provide adequate, correct, and consistent information to community members.

In general, the Nigerian map revealed that most of the communication strategies identified aimed to inform and educate and remind or recall. Few aimed to teach skills, enhance community ownership, and enable communication. The researchers did not identify any intervention that aimed to provide support or facilitate decision-making. Many interventions had more than one purpose. The main intended audiences for most interventions were caregivers and community members, with few interventions directed at health workers. Most interventions identified were used in the context of campaigns rather than routine immunisation programmes.

To cite an illustration of the latter, the category of interventions to inform and educate was the most common category applied in Bauchi State for campaign purposes and sought to reach community members. Commonly employed communication interventions included: engaging traditional and religious leaders; Quranic teachers; volunteer community mobilisers (lay health workers); polio survivors; organisations such as the Federation of Moslem Women Association of Nigeria, 'Journalists against Polio', and 'Doctors against Polio'; as well as celebrity spokespeople (political or traditional leaders). These all served as polio vaccine advocates to sensitise community members. The mass media (e.g., community radio and television) were also frequently used to deliver information about immunisation campaigns. Bauchi State operates 10 community radio stations in the common local language (Hausa). A roadside film show conducted in communities in mobile vans (majidi) targeted beliefs about the cause of polio disease and negative attitudes towards polio. Majidi and community radio were commonly used in rural areas, and television messages were used in urban areas. Cassettes and CDs carrying vaccination messages, as well as print materials such as posters and banners, were also widely used. In addition, letters informing people about upcoming campaigns were sent to churches, schools, mosques, and traditional leaders, and announcements were made in churches, mosques, schools, and villages. Town hall meetings were common and reached out to men in the community, whereas compound meetings (meetings involving several households) organised by Muslim women associations were designed for women. Also, advocacy visits to relevant political and community opinion leaders were frequently conducted before campaigns to solicit support.

According to the researchers, the COMMVAC taxonomy allowed them to organise by purpose the complex range of interventions used in two states in Nigeria and was useful in identifying areas where communication efforts are concentrated and where gaps exist. They discuss some of these patterns in the closing section of the paper. For instance, there is a general lack of attention to training health workers in interpersonal communication skills, despite the fact that they serve as an important source of information for the general public and are the main drivers of vaccination programmes. "Training courses to update health workers' interpersonal communication skills may enable them to communicate vaccination messages more effectively and should be considered by planners. The map of communication interventions also raises questions about caregivers' views of communication interventions and how the interventions identified are being implemented, including barriers and facilitators to implementing vaccination communication interventions at scale. These questions will be addressed in forthcoming paper..."