Using Participatory Action Research to Improve Immunization Utilization in Areas with Pockets of Unimmunized Children in Nigeria

"This study shows that collection of evidence and integration of evidence into discussion/dialogue with stakeholders can lead to change. Leveraging existing structures and potentials enhanced effectiveness..."

In 2005, Nigeria adopted the Reaching Every Ward (REW) strategy to improve vaccination coverage for children 0-23 months of age. By 2015, Ogun State had 100% coverage in 12 of its 20 local government areas (LGAs), but eight had pockets of unimmunised children, with the highest burden (37%) in Remo North. A participatory action research (PAR) approach was used to facilitate implementation of local solutions to contextual barriers to immunisation in Ipara and Ilara wards of Remo North. This article assesses and seeks to explain the outcomes of the PAR to understand whether and possibly how it improved immunisation utilisation.

PAR involves iterative processes of reflection and action, carried out jointly with communities, health workers, and local government officials, to provide insight into complex, persistent, or unstructured problems and realistic, context-specific solutions to them. The approach emphasises collective enquiry and research, based on experience and societal history, and consists of a cyclical process of fact-finding, action, and evaluation that accounts for underlying social, political, economic, cultural, and ethical realities. A common ideology in all PAR designs is that research and action must be done "with" and "by" people and not "on" or "for" people.

Facilitated by a policymaker and academics on the research team, the PAR consisted of two (4-month) research-informed dialogue and action cycles during 2016 and 2017. Participants included: community women and men, frontline health workers, and Remo North local government officials (e.g., representatives of the ward development committee (WDC) and social mobilisation committee, or SMC). The researchers presented the results of a situational analysis at baseline (see Related Summaries, below) to the three types of stakeholders, who used them to identify problems influencing immunisation coverage and their possible solutions. In each ward, the actions and plans formulated per group were compared and discussed within the joint dialogue groups ("joint action committees", or JACs) to develop joint action plans (JAPs) for change. The JAPs were implemented by the JACs and WDCs in both wards.

The PAR was assessed using a pre/post-intervention-only design with mixed methods. Baseline (situational analysis) in May 2016 and endline assessments in April 2017 were carried out using mixed methods comprising a household survey (HHS) of 210 caregivers, secondary data analysis of the National Health Management Information System (NHMIS), 16 focus group discussions (FGDs) with community members, and 25 semi-structured interviews (SSIs) with stakeholders involved in immunisation service delivery. Data were analysed using the Strategic Advisory Group of Experts (SAGE) vaccine hesitancy framework.

At endline, assessment by vaccine card for children older than 9 months revealed a significant increase in those fully immunised, from 60.7% at baseline to 90.9% (p<.05). A significantly greater number of caregivers visited fixed government health facilities for routine immunisation at endline (83.2%) than at baseline (54.2%) (p<.05). Accordingly, the consensus in the FGDs was that immunisation utilisation by caregivers in Ipara and Ilara for their children had improved in the past year. Most policymakers and local government officials commented that the coverage data from Remo North now showed fewer red and yellow indicators, indicating that the number of unimmunised children was declining, and immunisation-seeking behaviour had increased.

A key factor in this progress was identified as collaboration among the three stakeholder groups, which enabled the development and implementation of solutions to identified problems. The reasons reported by caregivers for improved utilisation of routine immunisation services were increased community mobilisation activities and improved responsiveness of the health workers. Some of the respondents in the FGDs described improved relationships between the community members and health workers that had resulted from the dialogues and action.

Overall, there was evidence of knowledge and awareness of immunisation and its value. A notable difference at endline was that the young women FGDs in both wards spoke more knowledgeably about immunisation and contributed more to the discussions than at baseline. Furthermore, at endline, there were more frequent reports from the young women in both wards about passing on information about immunisation to their neighbours. Leaders of the non-indigenous groups were reported to provide information on immunisation to their groups in both wards. This information usually related to the dates and times of immunisation, the value of immunisation, and information on adverse events following immunisation (AEFIs). The content of the information was provided by the health workers, and the language barrier was overcome by the use of these mediators.

JAC members in Ilara stated that home visits by health workers, especially in the course of tracking defaulters, provided opportunities for the husbands to be educated on AEFI. Nevertheless, some young women in both wards still commented that AEFIs were distressing and discouraging.

Caregiver knowledge regarding who the SMC members were increased significantly at endline, from 20.5% to 48.1%, and their knowledge of WDC members also increased significantly, from 27.1% to 52.4%. Multivariate logistic regression showed that children over 9 months of age were 3.68 times as likely to be fully immunised when caregivers had knowledge of SMC members (confidence interval (CI) 1.44-9.46).

The involvement of the local government implementers resulted in a spillover of the strategies used in the JAPs into other wards in Remo North. Monitoring data showed that functional WDCs increased from 100 pre-PAR to 164 post-PAR. Correspondingly, immunisation coverage in Remo North increased from 66% in 2016 to 86% in 2017, and the proportion of unimmunised children dropped from 30% to 9%. While the trend in immunisation uptake cannot be attributed solely to the PAR, it appears that the intervention was an important contributor to the acceleration of the upward trend in coverage.

The researchers note that caregivers with a higher level of education were 5.44 times as likely to fully immunise their children as uneducated caregivers. This association was stronger at endline than at baseline and suggests the need to include more uneducated caregivers in subsequent interventions. The role of external facilitation in the process also has to be noted.

In conclusion: "The PAR resulted in contextual solutions to problems identified by communities in both Ilara and Ipara....There is a need for a longer period of implementation accompanied by research to gain a deeper understanding of the mechanisms by which the PAR worked."