Impact Evaluation Report 127
Coverage for routine vaccines falls short of the global target of Gavi, the Vaccine Alliance. Coverage is particularly low in low- and middle-income countries. A recent survey shows that less than a quarter of children 12–23 months of age are fully vaccinated in Nigeria (NBS and UNICEF 2017). The reason for the low coverage is said to be multifactorial. Among these factors are poor parental knowledge and attitude.
A previous study used traditional and religious leaders (TRLs) in northern Nigeria to tackle the challenge of poor attitude demonstrated by parents towards polio vaccination. The study found that polio vaccination coverage had scaled up. The TRLs are perceived as influencers and have been used by governments at various levels to intervene on matters of communal interest.
Our aim was to measure the impact of engaging the TRLs in influencing vaccination uptake in Cross River State, Nigeria. Some experts have suggested the adoption of a multifaceted intervention to address gaps in vaccination based on local needs. Our study adopted such an intervention and included: training TRLs on vaccination, their leadership role and community mobilisation; training health workers to share vaccination data; and revitalising ward development committees.
Eight local government areas in Cross River State were selected for the study. The TRLs had eight training sessions during an 18-month intervention period. Health workers had three training sessions to summarise data and share vaccination data with the TRLs. Ward development committees were reactivated. A total of 2,598, 2,570 and 2,550 children aged 0–23 months of age were assessed through baseline, midterm and endline surveys, respectively.
The results showed that the intervention had no impact on the proportion of children with up-to-date vaccinations (p = 0.69). However, it was effective in reducing the number of unvaccinated children from 7 per cent to 0.4 per cent (p = 0.001). It was also effective in improving the timeliness of the later vaccinations in the schedule: pentavalent 3 (odds ratio (OR) 1.55; 95% confidence interval (CI): 1.14–2.12; p = 0.005) and measles (OR 2.81; 95% CI: 1.93–4.1; p < 0.001). These impacts had already been observed by the midterm survey and were maintained at the time of the endline survey. In terms of cost-effectiveness, the marginal cost-effectiveness ratio, relevant for scaling up the intervention, was USD34 per additional measles case averted.
The TRLs are untapped community resources who can be used to support vaccination uptake. Informal training to enhance their knowledge on vaccination and their leadership role can empower them to be good influencers for childhood vaccination. Their impact has a good prospect of being sustainable, as it drives demand and the TRLs take on responsibility for supporting vaccination services in their respective communities.
Vaccination programme managers and health workers involved in providing vaccination services should, therefore, advocate for the active engagement of TRLs in planning, implementing and monitoring vaccination services. Policymakers should incorporate the engagement of TRLs in vaccination delivery policies. There is, however, a need to explore the reason for the intervention’s lack of impact on the proportion of children with up-to-date vaccinations.