Exploring Factors Influencing Immunization Utilization in Nigeria - A Mixed Methods Study

"...a need for locally context-specific strategies and approaches to addressing the issues related to vaccine hesitancy and immunization utilization."

In 2005, Nigeria adopted the Reach Every Ward (REW) strategy to improve vaccination coverage for children aged 0-23 months. With a focus on routine immunisation (RI), REW includes components such as improved access for under-served and hard-to-reach areas, supportive supervision, monitoring and use of data for action, community mobilisation, and community linkages with service delivery, such as the Ward Development Committee (WDC) and the Social Mobilization Committee (SMC). Despite these strategies, by 2015, 8 of Ogun state's local government areas (LGAs) had pockets of unimmunised children, with the highest burden (37%) in Remo North. This study aimed to identify factors in Remo North influencing the use of immunisation services in order to inform intervention approaches to tackle barriers to immunisation utilisation.

The researchers carried out a cross-sectional study using mixed methods including a household survey (HHS) of caregivers of 215 children, 25 semi-structured interviews (SSIs) with stakeholders involved in immunisation service delivery (including members of the WDC and SMC), and 16 focus group discussions (FGDs) with community men and women (n = 98). The best and worst performing wards in Remo North - Ilara (with only 26% of children fully immunised in 2015 - and Ipara (with 76% fully immunised) - were purposively chosen for the study. Data were collected in May 2016 and analysed using an adaptation of the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Vaccine Hesitancy model.

This study was the baseline for a participatory action research (PAR) on immunisation. The researchers took a systems perspective: Since the REW strategic components have community participation elements, they also explored the policies on community participation and action.

Only 56 children (32.6%) of the 172 children over 9 months of age had immunisation cards available for inspection. Of these, 23 (59.6%) were fully immunised, noticeably higher in Ipara than Ilara. (Overall, vaccine hesitancy was exhibited more in Ilara than Ipara.) However, when immunisation status was assessed by card and recall, 84.9% of the children were assessed as fully immunised.

Contextual influences on immunisation utilisation included:

• Culture and ethnicity - For example, FGD participants described several traditional festivals as events where the women were unable to bring their children for RI due to traditional rituals and imposed curfews. Poor immunisation utilisation by migrants was perceived as mainly due to their cultural beliefs, especially those that valued traditional above western remedies. In addition, the Cotonous were reported to refuse immunisation for their children mainly for reasons associated with lack of trust in the quality of the health services, their preference for home deliveries, language barriers, and their occupation (farming).
• Gender relations/roles - The majority of caregivers (all females) in the HHS (88.6%) reported they were the ones who made the decision to immunise their children. However, even if women wanted to immunise their children, they could not do so if their husbands did not agree or if their husbands' mothers refused. In addition, the young women listened to the elders, which affected their decisions to immunise their children.
• Geographic barriers - A disadvantaged group mentioned especially in the SSIs were people living in hard-to-reach areas like Aba James and Ifote, which had difficult terrains and were usually inaccessible during the rainy season.
• Policies and politics - According to the policymakers and local government officials interviewed, there are national and local policies supporting community participation and action in immunisation. They noted that successful adoption and implementation within the local contexts were reliant on cooperation from the community leaders and community members, with monitoring being key. The SMC is responsible for immunisation campaigns and community mobilisation, as well as conflict resolution relating to immunisation issues in the wards. The WDC provides a gateway to the communities and support in community mobilisation and outreach. Respondents in the survey named the SMC and WDC as the main community structures linked to immunisation and important sources of information regarding immunisation. Those in Ilara noted that the WDC had been defunct in the ward since 2014 due to excessive politicisation of the committee, which led to the loss of interest of the traditional ruler. The Ipara WDC was also described as being politically motivated but rated as functioning well by the older men and women groups.

Individual and group influences included:

• Knowledge and awareness - Caregivers in the more rural Ilara had less knowledge of vaccine schedules. The importance of all doses was recognised more by Ipara respondents (95.5%) than in Ilara (75.3%) (p < 0.05). Most policymakers and local government officials said there was a need to improve awareness and knowledge for all the groups. Some described an issue whereby some caregivers would think their children had completed vaccinations by taking only one vaccination. Traditional and religious leaders in both wards noted that awareness and knowledge were hampered by insufficient health education. Health workers were reported in the survey (85.2%) as the most important (and commonest) source of information about immunisation. This finding was supported by the FGDs.
• Beliefs/attitudes - Common beliefs mentioned by the caregivers in the FGDs include beliefs that immunisation: kills children; was the "white man's" way of achieving family planning and population control; and could cause deformities or paralysis in children. Many respondents (especially the older women and men) in the FGDs said that they did not believe this anymore having seen the benefits of immunisation. In both Ilara and Ipara, vaccine hesitancy was most frequently reported for measles vaccine compared to the other vaccines on the immunisation schedule.
• Health services factors - The presence of antenatal and delivery services in the health centres played a key role in driving immunisation utilization. This was seen in Ilara, where FGD respondents reported that the absence of delivery facilities discouraged women of all tribal groups from using immunisation services at the facility. Community members' perceptions about conditions of the health facilities were mostly unfavourable. Respondents described the shortage of health workers as an important issue linked to the availability of vaccines.
• Experience with past immunisation - There was consensus in the FGDs in both wards that adverse events following immunisation (AEFIs) were the greatest demotivating factor against completion of immunisation. AEFIs were also the reason for reported loss of confidence by the community members (especially young men in both wards) in the quality of vaccines and loss of trust in the competence of the health workers.

Vaccination-services-specific influences were related to reliability of vaccine supply, costs, and role of health care professionals. For instance, respondents complained about health workers not sending reminders on time about RI or outreach days, and they blamed them for AEFIs.

The researchers urge that low immunisation coverage (26%) in Ilara points to a critical need for swift, practical solutions, including: increasing awareness and knowledge of the vaccination schedule, improving the condition of the Ilara health facility (and provision of antenatal and delivery services), and reviving the WDC in Ilara to ensure effective community mobilisation and drive demand for services.

That said, the researchers observe that many of the contextual factors identified in this study cannot be easily addressed, since they are entrenched in the cultural and political strata. However, the social mobilisation structures (WDC and SMC) are already embedded in the design of the vaccination programme, and strategies can be developed to strengthen these (and minimise political interferences) in order to drive the social and behavioural change needed to overcome vaccine hesitancy and improve immunisation utilisation.

In conclusion, immunisation utilisation in Remo North was found to be influenced by interlinked community and health services issues. Intervention approaches should ensure that communities' priorities are addressed, actors at all levels are involved, and strategies are adjusted to suit particular contexts.