Youth Group Engagement in Noncompliant Communities During Supplemental Immunization Activities in Kaduna, Nigeria, in 2014

"Systematic engagement of youth groups has a great future in polio interruption as we approach the endgame strategy for polio eradication."

Noting that one of the major challenges being faced in the Global Polio Eradication Initiative (GPEI) programme is persistent refusal of oral polio vaccine (OPV) and harassment of vaccination team members by youth, the objective of the study was to describe the strategy, and explore the impact, of collaborating with recognised youth groups in Kaduna State, Nigeria during supplementary immunisation activity (SIA) campaigns. As noted here, in 2014, security threats to vaccination team members were prominent especially in Igabi, Kaduna North, Zaria, Giwa, Soba, and Kudan local government areas (LGAs). On several occasions, apart from OPV vaccination refusal, team members were assaulted and their immunisation materials destroyed, with a resultant increase in the number of children chronically missed by SIAs (hereafter, "missed children").

To address this problem, an intervention was introduced in May 2014 to identify young people from several areas in OPV-refusing communities in the Rigasa and Tudun Wada communities in the Igabi and Zaria LGAs, respectively, of Kaduna State. Youth hailed from existing youth associations in the affected communities, motorcycle riders (known as Achabas), local vigilante groups, and Motor park tout (someone who provides services at the motor park). They then participated in a youth forum, which was coordinated at the LGA and settlement levels through the appointed leaders at the respective levels. The leadership of the youth groups worked in collaboration with security agents and traditional leaders. As part of this process, relevant information, education, and communication (IEC) and sensitisation materials were developed. Sensitisation sessions were conducted for 1 day with the youth, using lecture, discussion, and role play.

During the polio vaccination campaign, the sensitised youth were deployed to areas of documented noncompliance and vaccination team harassment. The youth worked with the vaccination teams for 7–8 days (2–3 days for directly observed oral polio vaccination (DOPV), 4 days for house-to-house vaccination, and 1 day for mop-up activities). They supported the vaccination team members in carrying and distributing "pluses" (such as sugar and milk satchets given to vaccinated children), as well as crowd control during DOPV and at health camps. In some instances, they also provided entertainment to the community during DOPV. The LGA youth leader and cluster or settlement youth leaders supervised the activities of members through regular telephone calls and routine checks, and they were complemented by senior supervisors from the state and the partners assigned to the LGA or ward. For any incidents or reports of threat or harassment of any team members, the cluster or settlement youth leader contacted the LGA PEI youth leader, and they jointly attempted to resolve the issue. However, in cases of violence or security threats beyond the capacity of the youth leaders to handle, traditional and security agents are invited for intervention. Daily evening review meetings with polio SIA personnel were conducted at ward and LGA levels, during which WHO staff in the respective LGAs collated issues, challenges, and data. After each polio vaccination campaign, data from the affected communities were collated and analysed. Feedback and debriefing were organised with the youth leaders in attendance, together with representatives of traditional leaders.

The researchers evaluated the impact of the intervention by using qualitative and quantitative methods. They found that the proportion of missed children, as shown in Table 1, decreased in Igabi LGA in all 8 rounds of the SIAs except round 8. The lowest proportion of missed children before the intervention was 7%, while the lowest proportion of missed children after the intervention was 2%. For Zaria LGA, the proportion of missed children decreased in all the rounds after the intervention, compared with before the intervention. The lowest proportion of missed children before the intervention was 5%, compared 1% after the intervention. Lot quality assurance survey data showed a reduction of nonaccepted vaccination results after the intervention (see Table 2). During the 8 rounds assessed as shown in Table 3, in Igabi LGA, the 4,126 noncompliant households in round 3 decreased to 778 after the intervention. For Zaria LGA, the number of noncompliant households decreased to 81 from 489 before the intervention. Statistical analysis of monitoring data (percentage of missed children), as shown in Table 1, using the paired t test, the mean percentage (±SD) was 11.6% ± 5.0% before the intervention and 7.9% ± 5.6% after the intervention. The P value was .002, indicating a significant decline in the percentage of missed children. As shown in Table 4, team harassment per round decreased from >10 incidents to 5 incidences in the ward. In November and December, there was no record of incidents of team harassment. In addition, there was a positive outcome in terms of reduced poliovirus detection in the affected settlements. There has been no reported circulating vaccine-derived poliovirus (cVDPV) recovery from environmental samples in Rigasa, Igabi LGA, since the implementation of youth group engagement, although more studies will be needed to support this finding.

In addition, the researchers found that the teams were more confident to inquire about the 6 interpersonal communication skill messages (number of children in the household aged 5 years; whether any children were absent, sick, or sleeping; and whether any visiting child or resident child had sudden weakness of any of the limbs), more assertive in convincing mothers and caregivers to accept OPV, and less fearful in marking households. The youth groups, after undergoing orientation, act as so-called polio ambassadors and, over and above protecting vaccination teams, sensitise fellow youths, and sometimes assist teams in persuading their colleagues to allow children in their wards to be vaccinated with OPV.

In the discussion section, the researchers explain these results by pointing out that "[t]he presence of the youths gave assurance and a sense of security to vaccination teams, making it easier to reach chronically missed children inside households during house-to-house vaccination and outside households during DOPV. The innovation greatly improved operations and the quality of SIAs in very high-risk communities in Kaduna State. Youth engagement is an innovation that, over time, has gained acceptance across stakeholders and enhanced vaccination team safety in OPV-refusing communities in Kaduna State."