Background
Methods
Study setting
Study sites
Study design
Sampling
Level | Respondent | Total |
---|---|---|
National | Senior communication staff at UNICEF, WHO, GAVI and the National Polio Emergency Centre | 4 |
State | Social Mobilization Officer (State Health Educator) (two in Cross River and one in Bauchi) | 3 |
Deputy Director, Community Health Services (Bauchi) | 1 | |
State Immunization officer (one in Cross River and one in Bauchi) | 2 | |
Deputy Director, Immunization Services (Bauchi) | 1 | |
Local | Local Immunization Officer (Bauchi/Cross River) | 2 |
Local Social Mobilization Officer (Bauchi/Cross River) | 2 | |
Total | 15 |
Data collection methods
Data analysis
Results
Health system factors
Financial constraints
“In October 2012, when we had a campaign for meningitis, Nigeria’s communication budget for that campaign was only two percent of the total budget for the campaign and yet we expect miracles to happen. Same way, if you look at the communication budget in other programmes, I’m sure you will be shocked to see that communication always receives the least budget. So, if this does not change – because one thing in communication is that what you give in is what you get out and communication is not something you do once and you stop.” (Decision maker, national level)
“In terms of funding, especially for campaigns, funds are provided but it is never enough for our planned mobilization activities. This affects the range of activities one performs. Most times, we have to use our own funds to succeed. If you want a wider coverage, they may give you funds for a specific number but you may go out of your way to reach more people.” (Mobilization officer, Cross River State)“I use my salary now to do my activities, especially for routine immunization activities, to meet up and be able to present my report at the State meeting.” (Local social mobilization officer, Bauchi)
Inadequate infrastructure and equipment
“A lack of mobility is a major challenge. You definitely cannot carry out an effective social mobilization work without mobility because you need to cut across many places. We do not have any vehicles attached to this department.” (Mobilization officer, Cross River State)
Human resource factors
Health worker shortages
“Every health worker wants to work in the urban areas, especially those whose husbands are politicians, and every big man wants his wife to be in the urban area. So when you transfer them it’s a big problem. This has resulted in many of them in the urban and very few health workers in the rural areas.” (Immunization Officer, Cross River State)
Training deficiencies
“You will find out, especially at the local government level, that the local Social Mobilizers who are saddled with communication assignments are not trained communication personnel. So you end up training and training and training. Some people are not just trainable.” (Development partner)
Poor attitudes of health workers and vaccination teams
Political factors
Failure of state and local governments to own the vaccination programmes
“If the states and the local government own this programme, you don’t need money from partners. For instance, a state that owns a radio station, a television station, you see all these stations should have been running free jingles. But they never do that. If you want to run anything, they ask you to pay even if it is their own children and mothers that will benefit. If there is ownership, those things will not happen, it is only once in a while in some States during campaigns you see them giving those orders. Immediately after the campaign, announcement stops.” (Development partner)“At the national level the states are asked to develop their communication interventions and thereafter they don’t have money to implement, and expect funds from the national to implement this and that hardly happens except for the funding that UNICEF sends because UNICEF is the mandate agency for polio communication.” (Development Partner)“We, the partners, are running after the government in some states whereas in other states, even when you go there and take over the driver’s seat, it is still almost impossible to drive the government to follow you and you can’t be at the forefront of any programme because the communities will still not see you as one of theirs. They hardly ever have enough funds to implement communications activities in the context of health programmes.” (Development Partner)
Health communication interventions not a priority among policy makers
“In our national budgeting, health is not one of those areas that attract funding. Even when immunization is considered, the funds allotted are usually for other technical components and communication is rarely considered and this trickles down to the local government level. Because if the national government does not allocate adequate resources to health or communication, the states will not see any reason to do that, so this now boils down to who is in charge. If the person in charge does not have an interest in health, then health is treated as unimportant.” (Development Partner)
Community level factors
Attitudes of community stakeholders
If you go to the community now they believe you came with money to give them. If you don’t give them they will sabotage your activities so that is why we have problems. Because you need people to come and get immunization sometimes we have to give them some incentives before they help in delivery of vaccination messages. I had an experience in the past when you go into the community, they say to you, “You people are enjoying yourselves under air-condition and driving big cars and yet we are suffering”. So once you give them something they cooperate with you and take the messages to their communities.” (Senior Health officer, Bauchi)
Attitudes among community members
“Refusals of polio vaccine still persist in some communities. There is a video tape being circulated by one Muslim teacher discouraging people against vaccination which led to a lot of rejections of the polio vaccine and resulted in our vaccination teams embarking on house-to-house immunization to be attacked because of the tape” (Local Social Mobilizer, Bauchi)“People are very hesitant when it comes to immunization campaigns, and have a phobia for polio campaigns in this part of the country. That is why our most important problem is this one. Even when people have heard about the campaigns through radio messages and are aware of it, they are still sceptical about immunization campaigns generally. People accept routine immunization but the campaign is what they are rejecting. They believe they go to the clinic and come back, but for the campaign why do we then come to their houses? They get suspicious and think there is more to it than we are telling them, which is why they reject it. But for the routine they go to the hospital and clinic. They don’t have any query or complain about it.” (Senior Health officer, Bauchi)
Engagement of traditional and religious institutions
Organisation of communication committees
Discussion
Health system issue | Key findings from the analysis | Implications for the strengthening of the health system to support vaccination communication |
---|---|---|
Funding of vaccination communication interventions | • Least budgetary allocation to communication and social mobilization • Funds/incentives seldom available for routine immunization and some costs borne by health workers • Overdependence on donors • Problems and delays with disbursement of funds and materials at lower levels of the health system • Lack of funding for sustained communication programmes for routine immunization • Communication strategies intermittent (minimal between campaigns) | • Consider improving the funding allocation to communication activities, which should be continuous even after campaigns • Provide a regular source of funding for routine immunization communication activities in the recurrent budget of States and Local Government Areas as this may improve sustainability • Ensure that systems are available for the management and timely disbursement of funds within vaccination communication programmes, especially at the local level |
Equipment and transportation | • Lack of equipment (information, education and communication (IEC) materials, megaphones and vehicles) for adequate mobilization • Transportation difficulties | • State and local government Social Mobilization Committees and Health Promotion Departments should be strengthened to develop their own IEC materials |
Human resources for health | • Generally seen as inadequate • Inequities in distribution of human resources, with more resources in the urban than in rural Local Government Areas | • Consider redistribution of health workers, temporary staff from the pool of retirees or community volunteers who can serve as mobilizers • Consider providing incentives for health workers in rural settings |
Training | • Lack of human resources for supervision of frontline health care providers • Training deficiencies, with large numbers of communication personnel not sufficiently skilled • ‘Cascade’ training model results in dilution of training efforts | • Establish a system to monitor the appropriateness and quality of training activities at the local level • Training needs assessments should be conducted from time to time • Supervision of Local Government Area mobilizers by state social mobilisers should be strengthened • Frontline communicators in the various Local Government Areas should be provided with training guides or manuals which can be tailored to meet local needs |
Health provider attitudes | • Health providers, including vaccination teams, poorly motivated | • Ensure that vaccination teams are provided with incentives |
Attitudes of parents and caregivers towards vaccination | • Vaccine hesitancy and rejection in some religious groups may impede receipt of vaccination information | • Engagement of traditional and religious institutions and other community structures may be useful in countering refusal in some communities |
Political support | • Political support focused on campaigns only • Failure of State and Local Governments to take ownership of programmes • Health communication not seen as a priority by some policy makers • Lack of political commitment in some Local Government Areas | • Regular advocacy visits to political leaders • Improve accountability systems, particularly at the state and local government level, to prevent misappropriation of funds meant for the communication needs of the vaccination programme |
Community participation | • Lack of community participation | • Consider evidence–informed and locally appropriate interventions to involve communities in planning and implementation of communication intervention for both routine immunization and campaigns |