Community Engagement Strategy for Increased Uptake of Routine Immunization and Select Perinatal Services in North-west Ethiopia: A Descriptive Analysis

"The 'Fifth Child' project likely contributed to enhanced immunization performance and increased utilization of immunization and select perinatal health services..."

Ethiopia is one of 35 World Health Organization (WHO) Member States that fell short of the 2015 Global Vaccine Action Plan (GVAP)'s goal of 90% national pentavalent-3 coverage. In Benishangul Gumuz Regional State (BGRS), specifically, primary reasons for low immunisation coverage include: misunderstanding of the schedule, poor healthcare-seeking behaviour, lack of confidence in the health system, limited access to services and irregular outreach sessions, low capacity among health workers, and vaccine shortages. To address these issues, the International Rescue Committee (IRC) implemented an enhanced community engagement strategy, the "Fifth Child Project-Closing the Immunization Gap" (FCP), across 2 woredas (districts) of BGRS. This study assessed FCP performance by reviewing trends in uptake of routine immunisations, defaulter tracing, and select perinatal services.

The FCP was iteratively developed and implemented in all 114 kebeles across Assosa and Bambasi woredas between 2014 and 2016, with key tools designed in consultation with the regional health bureau and woreda health offices. The intervention had 4 components:

1. A colour-coded health calendar (CCHC), called Enat Mastawesha, or "mother's reminder" in Amharic language, which aimed to improve understanding of the timing and purpose of critical maternal, neonatal, and child health (MNCH) services. Female health extension workers (HEWs) distributed calendars to all households with pregnant women or infants during home visits, placing colour-coded stickers on appointment dates to help remind families when to visit facilities. The IRC trained HEWs directly and facilitated HEW-led trainings for female-led health development army (HDA) and HDA leaders (HDALs) on improving interpersonal communication skills for effective, tailored, counseling sessions.
2. A defaulter tracing tool (DTT), which is a simple carbon-copy registration form used at the health post to record, by village, basic infant/caregiver information and vaccines missed. Defaulters were discussed using the DTT during bimonthly kebele command post meetings as a way of monitoring immunisation performance. The HDAs then conducted home visits to counsel families whose children defaulted, or were never immunised, to promote catch-up vaccinations. After household visits were conducted, HDAs reported back to HDALs.
3. An intervention to foster ownership and ongoing feedback between communities and health posts related to immunisation services. HEWs and HDALs informed kebele leaders (and often HDAs as well) of any defaulters and participated in mobilising caregivers to attend immunisation sessions at the health post or during outreach. Serious or unresolved issues from health facility or kebele meetings were presented at quarterly woreda meetings, also attended by woreda health officers and kebele leaders, for further discussion and resolution.
4. Basic health system support, addressing key service delivery gaps within the Health Extension Program (HEP). Underlying activities included: basic cold chain maintenance, vaccine transport, support for outreach, and training and supervision of HEWs in family planning (FP) counselling and provision of short-term FP methods and implants.

The formative evaluation found that, between January 2013 and December 2016, pentavalent-3 coverage increased from 63% to 84% in Assosa, and from 78% to 93% in Bambasi. Both were among the woredas that achieved greater than 80% pentavalent-3 coverage in the 2015/16 Ethiopia Demographic and Health Survey, compared with a national average of 53% and BGRS regional average of 76%. The 85% target for measles coverage was achieved in Bambasi (86%), but not in Assosa (81%), perhaps because Assosa is nearly twice as large as Bambasi and has more hard-to-reach areas. These rates still exceed the 80% district coverage recommended in the GVAP, the BGRS regional average (71%), and the national average (54%).

Approximately 54% of all eligible infants across both woredas defaulted on scheduled vaccinations at least once during the period. Among defaulting children, 84% were identified and subsequently caught up on the vaccinations missed.

Secondary outcomes of postpartum FP and antenatal care also increased in both woredas. This may be due to early engagement with pregnant women and key household decision-makers during facilitated discussions using the Enat Mastawesha and increased capacity of the HEWs in interpersonal communication, counseling skills, and implant insertion.

Reflecting on the findings, the researchers suggest that:

• Basic HEP supportive activities implemented by the project allowed for more stable immunisation delivery both at static posts and through outreach, ultimately reaching more infants and reducing the burden of travel time and costs for families.
• Capacity building of HEWs in interpersonal communication and consistent supportive supervision may have also contributed to increased utilisation.
• Well-functioning health systems have been shown to improve service availability and boost community confidence, possibly also increasing demand for services.
• The appointment reminder system (CCHC) may have contributed to reducing defaulters by creating a forum for health workers to provide MNCH education to mothers; caregivers who were visited at home by HEWs have been shown to have better immunisation completion rates.

"Further research is required to determine the extent to which project results are attributable to i) implementation of the cross-cutting community engagement approach and tools, in conjunction with HEP support, as compared to ii) basic HEP support from partners and iii) the HEP alone, without partner support." An impact evaluation, including a cost-benefit analysis of the approach, will follow the present study.