Contributions of Volunteer Community Mobilizers to Polio Eradication in Nigeria: The Experiences of Non-governmental and Civil Society Organizations

"The involvement of VCMs in Nigeria's PEI efforts has been a pivotal contribution to reductions in the number of households rejecting polio immunization, the proportion of families with missed children, the proportion of families that were non-compliant, and the number of polio cases."

Low immunisation rates in Northern Nigeria have been attributed to social and political factors such as vaccine hesitancy (caused by lack of trust in the vaccine or the provider, misunderstanding of the need for vaccination or of the effects of vaccination, religious beliefs, and rumours), poor access to health facilities, fear of violence, lack of knowledge, and illiteracy. Not surprisingly, then, the Northern states were the epicentre of the wild poliovirus (WPV) outbreak in Nigeria in 2016. To raise immunisation coverage, particularly of the oral polio vaccine (OPV), the Polio Eradication Initiative (PEI) in Nigeria introduced the use of non-governmental organisations (NGOs), civil society organisations (CSOs), and volunteer community mobilisers (VCMs) through the CORE Group Polio Project (CGPP). This article, which is part of a series of articles detailing the work of the United States Agency for International Development (USAID)-funded CGPP (accessible through Related Summaries, below), explores the contributions of the 2,130 VCMs deployed in 31 participating local government areas (LGAs) in the 5 implementing CGPP states from 2014 to 2017 to increase awareness, understanding, and acceptance of polio immunisation.

The article offers an overview of the PEI in Nigeria and the role, structure, and activities of the CGPP in this context. In brief, the CGPP is a multicountry, multi-partner initiative designed to strengthen country efforts toward polio eradication through NGOs and civil society. In Nigeria, the CGPP is referred to as the CORE Group Partners Project (hereafter also referred to as CGPP) to de-emphasise the use of the word "polio" in sensitive communities. In 2014, the CGPP joined the federal government and United Nations Children's Fund (UNICEF) to engage 2,250 VCMs, selected from the communities in the 32 participating LGAs in 5 implementing states, to increase awareness, understanding, and acceptance of polio immunisation. Three years later, the proportion of missed children and the proportion of noncompliant families, along with the number of polio cases, all declined in most local government areas (LGAs) in the polio-prevalent Northern states. In mid-2016, the World Health Organization (WHO) declared Nigeria a polio non-endemic country.

Data for the study were collected from primary and secondary sources using 5 collection methods: a survey of VCM supervisors, focus group discussions (FGDs) with VCMs and their supervisors, key informant interviews (KIIs) with community stakeholders, case studies of specific best practices of VCMs, and a review of documents and records.

The study revealed that the VCMs, who are females residing in the communities where they work, are well respected, have knowledge of the community's culture, can speak the local language fluently, and to some extent can read and write and have knowledge of polio immunisation. It is mandatory for VCMs, who work for a minimum of 24 hours per week, to wear CGPP-branded pink hijabs to respect the norms, culture, and values of their community. These hijabs function not only as the dress code for VCMs but are a form of community identification and recognition. Each VCM is assigned between 150 and 300 households in her community. On regular days, VCMs work individually with families in their assigned communities, documenting immunisation status, recording pregnancies and births, and providing information on vaccination and other health topics. "The rapport they develop with their families is paramount." VCMs also provide support prior to and during supplementary immunisation activities (SIAs) and Immunization Plus Days (IPDs).

A review of the data shows that the VCMs received comprehensive training on the importance of the PEI, routine immunisation, acute flaccid paralysis (AFP) surveillance, social mobilisation and community engagement, use of behaviour change communication (BCC) tools, and interpersonal communication skills. Multilevel supervision is described here as a key strength of the CGPP VCM network (see figure 5 in the article). According to the data collected, the VCMs used the following strategies to ensure high vaccination coverage: house-to-house mobilisation, naming ceremonies, compound meetings, community dialogues, community health camps, and tracking of non-compliant families, missed children, and dropouts (see table 3.)

VCMs deliver their messages verbally in coordination with a variety of BCC tools such as pictorial flip-books, stickers, streamers, banners, posters, danglers, wrist bands, fliers, and T-shirts. The BCC tools address the importance of vaccination and provide general knowledge on the immunisation programme, the safety of OPV, the number of doses needed for each vaccine, the route of OPV administration, and personal hygiene and nutrition. In fact, the VCMs deliver a variety of key messages to households. It has been demonstrated that families in Nigeria pay more attention to polio vaccination when VCMs engage families to discuss health practices such as breastfeeding, malaria prevention, hygiene, and sanitation together with polio. This may have informed the introduction of the concept of health camps during SIAs. Typically, health camps provide 3 separate booths: one for OPV, one for the other routine immunisations, and one for general health services, including the provision of oral rehydration salts (ORS), analgesics, and multivitamins.

As reported here, the VCMs work in close alliance with highly respected community leaders who serve as the bridge between the VCMs and their communities. The community leaders assist in selecting respected and influential women to serve as VCMs, help to resolve cases of immunisation defaulters or rejections and to mobilise their communities for immunisation activities, and participate in planning meetings and community dialogs. Specifically, the engagement of Muslim clerics, polio survivors, medical doctors, qur'anic/Islamic schoolteachers, Christian clerics, traditional rulers, and street entertainers have all provided key support in reaching missed children and non-compliant families, overcoming community resistance to immunisation, and reaching people in difficult and security-challenged terrains.

During the KIIs, community and women leaders commended the range of VCM activities, from providing health education and holding discussions during compound meetings to participating in naming ceremonies. This feedback underscores the need to provide accurate information to counter inaccurate beliefs on immunisation and vaccinations.

Further evidence of VCM effectiveness from the data collected include the following: resolving chronically non-compliant cases in settlements in the different states and, during compound meetings, using dramas and discussions on issues such as routine immunisation (including tetanus toxoid immunisation), which enabled the VCMs to clear up misconceptions on immunisation, gain the trust of mothers, and motivate them to have their unimmunised children immunised with OPV and other routine vaccines.

"There has been little to no turnover of VCMs in the project. This has been vital for consistency and allowed for strong lasting connections with the community. VCMs were selected by the community, are members of the communities where they serve, and have established lasting bonds with families. This strong connection and trust have allowed VCMs to succeed in mobilizing families for vaccination and have made them trusted advisors and sources of information. The CGPP endline evaluation demonstrated community reliance of VCMs, with 73% of caregivers in CGPP focal areas reporting that VCMs are the major source of information on polio in their communities."

Each year, about 500,000 children living in high-risk and hard-to-reach locations are reached by the CGPP VCMs in Nigeria. The CGPP has reached 1.4 million people with social mobilisation and health messages since the inception of the project in Nigeria (see table 4). This is approximately one-third (32%) of the estimated population of people older than 15 years in the 5 CGPP implementation states. Intensive mobilisation, resolution of non-compliance, and improved engagement of key stakeholders led to a decline in the percentage of missed children from 4.5% in FY2014 to 0.8% in FY2018 (see table 5). "This is a particularly notable achievement, given the security and accessibility situations in many of the CGPP focal areas." The CGPP VCMs supported vaccinators during this period in administering more than 1.7 million doses of OPV to children at the time of SIAs.

In reflecting on the findings, the researchers observe that the VCMs have acquired skills in community engagement, social mobilisation, AFP surveillance, and BCC. These competencies could be helpful for supporting other public health priorities, including routine immunisation, child health, control and elimination of neglected tropical diseases, integrated disease surveillance and response, health information system strengthening, and control and prevention of non-communicable disease. For these reasons, the lessons learned and the strategies used by VCMs could serve a resource for future programming to address broader health goals.

This article "shows that involving respected, trusted local women in health implementation can be highly effective, particularly when they are supported by other community influencers such as traditional rulers, religious leaders, community leaders, women leaders, and other opinion leaders. Providing referrals and information to address pressing needs of families outside of polio helped increase uptake and acceptance of the program and created trust. The VCM strategies were nimble, innovative, and tailored to the communities to address community challenges that arose." As part of the polio legacy, VCMs "are uniquely positioned to support routine immunization and to provide health education, data collection, active disease surveillance, and home visits for hard-to-reach populations for other health initiatives once polio is no longer endemic in Nigeria."