Lessons Learnt from Implementing Community Engagement Interventions in Mobile Hard-to-Reach (HTR) Projects in Nigeria, 2014-2015

"CE interventions implemented in the HTR settlements were instrumental to the steady increase in immunization coverage in these areas."

With the Alma Ata Declaration in 1978, community engagement (CE) became a cardinal principle in primary healthcare (PHC) in Nigeria. A number of studies on community mobilisation for maternal, newborn, and child health (MNCH) have demonstrated the importance of CE and participation. To that end, CE was implemented as a key component of the hard-to-reach (HTR) project that the Nigeria polio programme introduced in 4 northern states in 2014. (The term HTR is operationally defined as geographically difficult terrain, with any of the following criteria: having inter-ward/inter-Local Government Area (LGA)/interstate borders, scattered households, nomadic population, or waterlogged/riverine areas, with no easy to access to healthcare facilities and insecurity.) The project, which is ongoing, was set up to improve population immunity, increase oral polio vaccine (OPV) and other immunisation uptake, and support Nigeria's efforts to interrupt polio transmission. The CE strategy focused on addressing demand-side factors, using existing community structures to improve coverage. This paper describes the processes and methods for engaging communities and assesses the performance of CE structures and their impact on improving immunisation coverage in Bauchi, Borno, Kano, and Yobe states.

The process of integrating CE into the HTR project began with a baseline survey in the 4 selected states using focus group discussions (FGDs) and 174 key informant interviews (KIIs). Based on findings from the baseline study, the researchers developed a module to train HTR personnel on their roles and responsibilities in CE, as well as the benefits and importance of ensuring community involvement in the implementation of the project.

Next, the mobile HTR team leaders enumerated all households in the selected settlements during a micro-plan process to ensure community involvement and participation in the project. Mobile health teams (MHTs) convened meetings with community leaders to determine days, dates, and locations of immunisation posts and to identify town announcers, community mobilisers, and other community structures such as village development committees (VDCs). Each MHT leader then met with community leaders, community-based organisations (CBOs), town announcers, community mobilisers, women, youths, and VDC members to sensitise them on the importance and benefits of immunisation. The need to track defaulters and the referral of newborns to vaccination posts was also discussed.

Before the commencement of each vaccination session, the trained town announcers and community mobilisers traveled around their communities to mobilise caregivers to vaccination posts and to share information about the dates, time, locations, and antigens provided at those posts. Furthermore, the community mobilisers actually visited each house to converse with caregivers about the HTR services and respond to their concerns. Based on the orientation that was given to them, community mobilisers referred newborns and pregnant women to vaccination posts.

Traditional leaders, who served as the link between MHT and communities, mobilised attendees at mosques, churches, and public gatherings by informing their people about the dates and locations of immunisation services.

In the settlements where VDCs existed, VDC members mobilised communities to mobile outreach sessions. The VDC helped to create awareness, stimulate demand, and convince noncompliant communities to accept immunisation. The VDC members also tracked defaulters based on the data provided by the MHT.

The researchers conducted a mid-term review (MTR) in November 2015 to assess the progress of the HTR project. They administered structured questionnaires at the health facility and community levels to assess, among other issues, the level of CE and the utilisation of services. In the 2,311 settlements selected to implement the HTR project, participants involved in mobilising and creating demand for mobile outreach services during the period 2014 to 2015 included: 4,622 town announcers and community mobilisers, 2,975 community leaders, 1,170 CBOs, and 431 VDCs. Caregivers interviewed reported that community mobilisers (74%) had visited their homes; the highest was in Bauchi, with 92% visitation rate, followed by Kano (83%) and Borno (66%), with the lowest reports for Yobe (at 53%).

Forty-five percent of caregivers indicated that the community mobiliser was the person who mobilised them to the vaccination posts, followed by the town announcer (40%) and community leaders (30%). Overall, 51% of caregivers identified community leaders and town announcers as the main sources of information about mobile outreach services. Satisfaction with the work of community mobilisers was greater than 80% in all 4 states, with a high of 99% in Bauchi, 97% each in Borno and Kano, and the lowest in Yobe at 81%.

In addition, the researchers reviewed HTR data from June 2014 to June 2015 to determine the contribution of CE interventions to increasing OPV and the third dose of the pentavalent vaccine (penta3) coverage, which is a proxy for routine immunisation coverage. With the introduction of the project in the first quarter, OPV coverage for children below 1 year of age was 44%; this figure reduced in the second quarter but steadily increased to 54% and 76% by the fourth quarter. There are, however, variations in the number of children vaccinated against OPV by each state. Penta3 coverage in the first quarter for all states was 22% but, by the last quarter of the first year of the project (2015), it rose to 62%.

The researchers note that having a community mobiliser who is respected and resident in the community helped in the passage of the right information for caregivers to act by visiting vaccination posts. This highlights an essential element of this CE approach: It was not just about raising awareness about the services of the HTR project but about persuading community members to take action.

In conclusion: "With the current government plan to implement a 'PHC under one roof' (PHCUR) policy, the lessons from this study will help to shed light on how communities in the HTR and other difficult areas can be included in planning for mobile outreach services. Similarly, other time-bound projects could learn from the methods of this project for ways they can harvest CE results to increase immunization coverage within a stipulated time."