Evidence for "Whole Family Approach" in Accelerating Uptake of COVID-19 and Routine Immunizations among Integrated Primary Health Services in Nigeria

"The family is the simplest unit but possesses the strongest bond in society. These qualities - bond and proximity - that exist both within and across neighboring families...can be instrumental in shaping a new kind of health promotion strategy that can transform health behaviors in communities."

Launched in 2021, the Whole Family Approach (WFA) is a government-sanctioned approach to increase uptake of COVID-19 vaccines in Nigeria. The approach entails leveraging the high family-based demand for some primary health services, such as malaria, diabetes, hypertension, and reproductive services, to generate demand for COVID-19 and routine immunisations. Its goal is to close the gap between people and health services through integrated health promotion in the communities and opportunistic health promotion in the facilities. This study provides a theoretical framework for the WFA and tests the effectiveness of the strategy in increasing the utilisation of target services in a Nigerian community.

Family-centred care tends to be conceptualised around decision-making on treatment and patients' information management. In the WFA, family-centred care manifests primarily in the domain of health promotion. The approach aligns with four different theoretical models, which are described in the paper: the health-promoting family model, the Donabedian model, the health belief system, and Anderson's behavioural model for health services utilisation. The WFA emphasises the attempt to increase uptake of priority health services by simultaneously increasing key identified aspects of the factors of demand and supply. The demand side describes the choice of individuals or groups to seek health services, while the supply issues relate to accessibility, availability, and quality of health service delivery. In this study:

• The WFA is deployed on the demand side in the form of trackable information, education, and communication (IEC) print materials deployed through designated health announcers in each community and facility. For instance, a flier bearing a picture of parents and a child depicts the family-centredness of the programme at first glance. This aspect of health promotion is carried out by trained community health influencers who educate households on the benefits of the whole-family health service package at the primary health centre located within their community. Printed banners are also placed at conspicuous points in the facilities to opportunistically prompt health demand for the key services in the package.
• On the supply end, facilities are primed with training and data collection tools to provide and document health services. For instance, a child immunisation offer will be instructed about how to communicate with parents who brings their child for routine immunisation, advising them to consider taking the COVID-19 vaccine.

The data collection for this study spanned over a period of four months (May - August) in 2022. Two primary healthcare facilities were selected in two communities located in the Federal Capital Territory (FCT), also known as Abuja, in a quasi-experimental design. Prior to the intervention, a small-sample landscape assessment informed the project team of the low level of awareness of the community members about the government-sanctioned approach. Most of the facility managers at the intervention facility also had limited knowledge about the programme, despite offering the services required to implement the approach. The project team identified a communication gap between the facility managers and the agency leaders, which motivated the team to organise a capacity-building programme to emphasise the need to strengthen top-bottom communications in the primary health system. The project team further visited the facility to train staff about the approach, especially the community health influencers. A 6 ft-by-5 foot flex-banner was erected at the entrance of the facility to facilitate in-facility referrals for the services.

Family-oriented health promotion activities were facilitated in the intervention community (integrated health education by trained community health influencers - one male, one female) and facility (opportunistic health promotion through in-facility referrals) for one month. There were 5,870 participants in the intervention facility and 2,469 in the control facility.

At the end of the 1-month community sensitisation using the 100 tracked fliers distributed by the community influencers, trend analysis from the 4-month facility utilisation data harvested from the facility summary registers revealed that the WFA significantly increased service utilisation (N = 5,870; p < 0.001, α = 0.01, 99% confidence interval, or CI) across all the package services provided at the intervention facility. A supplementary Pearson's correlation analysis further presented a positive relationship (r = 0.432-0.996) among the services that favoured the result.

"The program was implemented on a small scale, influenced by limited availability of resources and administrative compliance....Although there is no significant level of correlation between the rates of uptake of COVID-19 and routine immunizations due to WFA, the positive association observed makes a moderate case for the integration of routine immunization and COVID-19 vaccination..."

In terms of future work and study implications, the researchers note: "With respect to future need for the strategy, it is important to state that the whole-family approach is capable of a wide range of flexibility in the mix of services, however, standards for choosing a services package is yet to be established....While there is more to be understood about this interesting approach, we recommend the improvement of communication and capacity gaps in Nigeria's primary healthcare system to ensure that promising strategies such as the WFA are adequately implemented at the community and facility levels."