Focus group discussions with caregivers.

The FGDs with caregivers included semi-structured questions that covered:

• Their sources of information regarding childhood vaccination
• The type of information they received
• Their perceptions of these communication strategies
• Their views of the best possible ways in which vaccination information should be delivered

Each focus group was made up of six to eight persons, a moderator, a note taker and an observer. We conducted the FGDs in primary health care centres on routine immunization clinic days in order to capture caregivers’ experiences of communication interventions provided during campaigns and routine services in the community and in facilities. Participants were seated around a round table to ensure proper eye contact and attention. The moderator, who was the principal investigator, facilitated the discussion and ensured equal participation. We obtained permission from participants to record the discussion. In Cross River, we conducted the FGDs mainly in pidgin English and Efik. In Bauchi, we conducted the FGDs in Hausa. We engaged an interpreter to assist with communication. Each discussion lasted about 30–45 minutes. The number of focus group discussions held was guided by practical constraints such as the amount of time available for data collection. We conducted interviews to cover urban and rural respondents and the number of group discussions was determined by the number of service users present in the health facility.We provided refreshments for participants at the end of each discussion.

In-depth interviews with health workers.

We invited the health workers for an interview at a time and date convenient for them.We aimed to interview two health workers per facility, the head of the facility and a health worker actively involved in providing vaccination services. However, in certain rural facilities only one health worker was seen manning all the activities in the clinic. We carried out the individual interviews in English, in the health facility, using an interview guide (SF2). Each interview lasted between 30–45 minutes and were audio-recorded after permission was obtained from the respondents.

Interviews with traditional and religious leaders.

We conducted interviews with one religious and one traditional leader in Bauchi State who were actively involved in the vaccination programme.

Observations of communication activities.

We carried out observations of routine immunization activities in six health facilities in rural and urban settings in both states over a period of four weeks. This was done after obtaining permission from the health worker in charge of each facility. We recruited three research assistants who could speak Efik and Hausa fluently and conducted a two-day training workshop for them. During the first week of observations, we had daily meetings with the research assistants to ensure that they were collecting accurate information. The research assistants conducted structured observations of one-to-one communication between health workers and caregivers during routine vaccination encounters; and of group health education sessions conducted on vaccination days.

We observed the following during our visits:

• The content of the communication interventions
• The frequency with which it was delivered and the format(s) used
• Who delivered the intervention
• Whom the communication intervention targeted
• Whether the communication intervention included information on other childhood interventions (e.g. nutrition breast feeding, diarrhoea management, etc.)
• The duration of each session

During the polio campaigns, held in both states, we also accompanied health workers during house visits in communities and observed how they communicated with the caregivers.

Data management and analysis.

We audio-recorded and transcribed verbatim all interviews and FGDs. Data that we collected in Hausa and Efik were translated into English. Two researchers (AO and GB) carried out data analysis using a framework analysis approach. It involved four steps: familiarization, indexing/coding, charting, and mapping/interpretation[26].First, we familiarized ourselves with the data collected in the interviews and the FGDs by listening repeatedly to the audio recordings and studying the transcripts. This helped us gain an overview of the body of material gathered and become aware of key ideas as well as recurrent themes. Next, we indexed and coded the data. To enhance coding validity, the principal investigator (AO) and a sociologist(GB)coded each transcript independently and later merged the codes to create a single coding book. When coding the data, we identified a number of themes, which we then organized under different sub-categories and categories in a chart which we subsequently populated with our textual data. Lastly, in the mapping and interpretation stage, we analysed the key characteristics as laid out in the charts, looked at patterns across and within the data and made preliminary explanations of associations with the data. We then used relevant data extracts to demonstrate key findings.

For the observations, we examined the observation notes and tried to identify patterns in behaviour and possible factors that could impede or enhance vaccination communication at the facility level. We then tried to link the findings from the observations to the findings from the interviews and FGDs, which helped to confirm or refute these findings.

Ethical approval.

We sought and obtained ethical approval from the Cross River State Health Research and Ethics Committee and Bauchi State Health Research and Ethics Committee. The Regional Committee for Medical Research Ethics in Norway assessed the project as not requiring ethical approval under the Norwegian Act on Medical and Health Research.

a) Clinic environment.

Most caregivers agreed that the clinic environment where vaccination messages were received played an important role in the delivery of vaccination information. More caregivers in both states reported that the environment was not conducive. Dissatisfied caregivers complained that the number of seats was not adequate and that they sometimes had to stand throughout the health talks or remain outside as the clinic could not accommodate them. This led to caregivers either missing the health talks or not paying attention to, or participating fully, during the talks.

“Because the ventilation in the health centre is poor, it gets very stuffy when there is a crowd, especially when first time mothers visit. Most babies become uncomfortable and start crying. Then their mothers have to carry them outside for fresh air and in the process may miss vital information about vaccination and child care.”(Caregiver, Cross River, urban site.)

b) Long waiting times.

Most caregivers in both states agreed that they had to spend a considerable amount of time in the health centre when bringing their children for vaccination. Caregivers described this as having both positive and negative effects. Some respondents, especially in Bauchi, were particularly happy about spending time in the clinic because it afforded them the opportunity to ask questions or share experiences, not just about vaccination but about childcare in general.

“The time I spend in the health centre is valuable to me so I don’t mind staying for a long time there. Apart from learning from the health talks given by the health professionals, I also use that time to learn from other mothers’ experiences and they also give me ideas on how to deal with some health issues. So, I will not say it is time wasted. For example, the health workers advise us to give paracetamol after the baby is given the penta vaccine but I realize my child still has high fever and is restless the whole night. But one mother advised that I should administer paracetamol before coming to the clinic and suggested a particular brand which I bought, did as she advised and the fever vanished.”(Caregiver, Bauchi, urban site.)

This was confirmed during the observations where caregivers met with other women or health workers and interacted, exchanged ideas, asked questions and learnt from one another while waiting for the clinic to commence. However, urban caregivers in both states complained that clinics commenced very late (10 AM)and went on for too long, usually closing at 2–3 PM.

Caregivers mentioned that they received talks from different people on various topics of interest, including the representative of a baby diaper company. Some caregivers believed that if the clinic started early and the information given was concise it would be more useful than starting late. They mentioned that most babies become irritable later in the day, leading mothers to pay less attention during the health talk. Another reason for long waits in rural sites was the delay in arrival of other mothers at the health centre. They explained that most caregivers usually came late to the clinic and the health workers would usually not commence until a sufficient number of mothers had arrived.

“I usually prefer coming to the clinic from 10 AM because the health workers usually like wasting time. So, I prefer going to my shop first and sorting things out before coming to the health centre. Because of this, I usually miss the health talks where I learn how to take good care of my baby and receive information on the vaccinations given to him. I wish they could start on time so that we can leave early and get back to our businesses.”(Caregiver, Cross River, urban site.)

We also observed that long waiting periods in the rural sites was a result of only one health worker being in charge of all clinic activities. One healthworker also gave reasons for the long waiting times experienced by caregivers:

“This is because we have to go to the cold chain store to collect the vaccine every day because our solar system [power supply] has a problem. Before now, we would collect it a day before and store it in our clinic. But because our solar system is bad we collect the vaccines on the day we want to use it and this causes a delay in the early commencement of the clinic. Also when we are expecting visitors (representatives from WHO, NGOs) to come we have to delay the clinic from starting until the visitors come.”(Health worker, Bauchi, urban site.)

c) Heath worker attitudes towards caregivers.

In both states, caregivers had varying opinions regarding the way in which health workers communicated with them. Some described health workers as being warm and friendly and treating them with respect. However, a few caregivers described the impolite behaviour of health workers towards women with low levels of education, teenage mothers and mothers who arrived late or forgot their vaccination cards. They explained that this behaviour could undermine trust in the health workers and could also discourage caregivers from listening to health education messages. One caregiver explained that once a mother is treated inappropriately, she may become resistant to any information delivered by the health worker and may resolve not to return to the health facility to continue with her child’s vaccination:

“If you don’t dress well and are not so educated some of the nurses treat you badly compared to others. This attitude usually leaves a lasting impression on the minds of the mother and she may miss vital information on vaccination because she refuses to listen to anything the health workers say. I almost fought with one of them [nurses] the last time I visited because of this behaviour.” (Caregiver, Bauchi, rural site.)

Some caregivers also reported that health workers gave preference to some women over others:

“I have noticed that the health workers don’t operate a first-come first-served basis and are usually partial to some mothers. You can get to the clinic very early but you may be the last to leave because if the health worker’s friend arrives, she will be given preferential treatment while others were abandoned. This usually makes some mothers stay at home or come late and miss important information delivered during the teaching session and some may never complete their wards vaccination.”(Caregiver, Cross River, urban site.)

This was confirmed during our observation visits during which we noted that caregivers who dropped off their vaccination cards and were registered early were not usually the first to receive vaccinations.

We observed that health workers were particularly warm and receptive on days when fewer caregivers visited. Health workers occasionally shouted at mothers who came late, could not answer questions asked, missed their clinic appointments or forgot their vaccination cards at home. In the rural sites, our observations also suggested that these health workers were usually not as friendly as urban health workers. This may have been tied to the fact that they were understaffed, with sometimes just one health worker in a facility performing tasks including the collection of vaccines from the central store, registration, vaccine administration, health education and cleaning. We rarely observed one-to-one communication in these rural settings. Only a few caregivers asked questions following a health education session while others were too timid. We observed that caregivers, especially latecomers, did not to go to the health workers to ask questions or to seek clarifications on their children’s health needs because of fear of being scolded. Rather we observed that they usually sought information from other caregivers at the clinic.

Caregivers’ preferred channels of childhood vaccination information.

In both states, a vast majority of urban caregivers reported that they preferred to receive vaccination information via text messages, including reminders of vaccination clinic appointments or upcoming campaigns. Most rural caregivers, on the other hand, wanted childhood vaccination information delivered to them through the town announcers. They suggested that town announcers should be engaged continuously to disseminate information, rather than during campaigns only. The media was a preferred means of communication for most rural and urban respondents in both states, but they stressed that the frequency of announcements and jingles targeted at childhood vaccination should be increased. More rural caregivers from Bauchi State, compared to Cross River State, preferred the radio as a means of communicating childhood vaccination messages. The availability of several community radio stations in Bauchi, where the local language (Hausa) was used to deliver information, and poor power supply, made the radio (which could use batteries) more preferred among rural caregivers.

Caregivers’ preferred information sources.

In both States, but particularly in Bauchi, traditional and religious leadersare highly respected. One of the caregivers from Bauchi explained why traditional institutions were strong and was a preferred source of information:

“In Bauchi State, most of us are Muslims and our traditional leaders are also Muslims so whatever they say stands and no one dare disobeys the traditional leader especially. So for us, if the Emir is for vaccination and he sends the town announcer to announce it or he tells us himself, everyone must obey. In other non-Muslim states there may be disagreements between the traditional and religious leaders.”(Caregiver, Bauchi, urban site.)

Preferred timing, frequency and content of vaccination information.

Caregivers noted that the timing and frequency of vaccination information was also important: Most caregivers wanted more detailed vaccination messages delivered more frequently at the right time and not limited to campaigns.

“We tend to hear about immunization only when there is a polio or measles campaign. After that no one hears anything again till another one is coming up so people may forget or think that is the only vaccination their children should receive. I think that they should emphasize that children should continue their immunization at the health facilities after the campaign. These campaigns bring a lot of confusion.”(Caregiver, Cross River, urban site)

Preferred targets for childhood vaccination information.

Many caregivers in Bauchi and a few from Cross River were of the view that targeting men should also be considered when delivering vaccination messages because most women do not take decisions regarding their children without partner consent. Approval from men ensured that necessary arrangements for vaccination, including transportation to the health facility, were made:

“For us here, if our husbands approve immunization then we do not have a choice because he will provide transport and ensure that we take the children for immunization. A woman cannot just get up on her own and carry her child for immunization in our community. If you are caught you may be sent packing from your marital home and he will take a new wife. Even for a widow, a man in the family must give approval first. This is why I am saying men should be targeted for information at the right time.” (Caregiver, Bauchi, urban site.)

Most rural caregivers suggested that vaccination messages and announcements should be delivered during news broadcasts because men mainly listened to the news, and that this should be done in the local language. Another caregiver stated that vaccination messages delivered in mosques should be given immediately after prayers to capture men’s attention.

a) Attitudes at community level.

Health workers in both states identified the attitudes of community members as responsible for vaccination rejection or resistance in certain communities. According to some health workers, certain community members in Bauchi and Cross River prevented health workers from gaining access to their communities, and this prevented them from delivering vaccination messages. In other communities, health workers said that they were sometimes physically attacked, especially when community members felt they had other pressing needs that were not being addressed by the government, such as good road networks, health care, schools for their children and employment.

One health worker noted that two forms of resistance could exist in a community: pocket resistance, where some families within a community refused vaccination; and block resistance, where an entire community refused vaccination. Some reasons cited as contributing to resistance included: misconceptions and rumours linked to religious beliefs, scepticism surrounding the polio vaccine and the perceived marginalization of hard-to-reach communities.

One health worker from Bauchi described how vaccine refusals were more common in the context of polio campaigns and less common in relation to routine immunization in health facilities. This health worker suggested that house visits during campaigns were viewed with more suspicion than vaccines delivered at clinics. This problem was sometimes addressed using community dialogues involving relevant community stakeholders, most often religious or traditional leaders. One religious leader noted that resistance was often linked to religious or cultural beliefs, but that community dialogue usually yielded results.

b) Poor interpersonal communication skills among health workers.

Various factors were linked to poor communication skill among health workers. In both States, many health workers reported that they received little training in communication. Most health workers in Cross River and a few from Bauchi reported that their only training in communication was received while in college. They pointed out that most workshops and training sessions on the provision of immunization services paid very little attention to the acquisition of communication skills and focused more on technical components of the programmes. Health workers argued that this may have decreased their ability to manage issues of resistance and deliver vaccination messages effectively.

“In most workshops I attend, the emphasis is usually on the vaccines to be administered, site of administration, storage and maintenance of vaccine potency, while communication is usually limited to the types of communication that can be used and the content to mothers bringing their wards for immunization. The actual act of communication is not demonstrated. (Health worker, Cross River, urban site)

One senior healthworker indicated that she had received training on vaccination communication, including the different methods that could be used in various settings, but that this training had taken place four years previously.

c) Lack of motivation.

Respondents identified a number of factors that undermined their motivation to communicate effectively with parents and communities. During the delivery of communication interventions, some health workers in Bauchi mentioned instances where they were embarrassed by community members who felt that the health worker was shabbily dressed. Consequently, these health workers were not allowed into their homes and were refused access to the children. As mentioned, there were also instances where health workers were attacked by community memberswhen visiting resistant homes or communities.

In Cross River, health workers reported that they had to travel for long distances to remote communities to deliver vaccination services. They also described instances when they were involved in accidents on these trips. They felt that the government rarely paid attention to these challenges, and that they received poor remuneration in relation to the risks involved. They also described how they sometimes had to use personal funds for communication activities but that these funds were rarely reimbursed. These problems discouraged healthworkers and contributed to poor delivery of vaccination information:

“I trekked a very long distance with vaccines on my head because there were no roads to the community. I have even walked through a forest all alone. I went through the hills, rock and had to cross through this rope bridge. I had to cross a deep river once which reached my stomach and it was a fast-flowing river. The risks involved can’t be compared to the stipend these [workers] are paid.”(Health worker, Cross River, rural site.)

Comparing health workers’ and caregivers’ views on useful channels for vaccination communication.

Table 2 compares the preferred sources mentioned by health workers and caregivers. Health workers identified several channels of vaccination information which they felt were useful for caregivers. The most commonly mentioned sources for rural communities were town announcers and traditional and religious leaders whom health workers believed to be useful because they were accessible and acceptable to people. The health workers opined that mothers usually felt important when health workers visited their homes, and that the women usually opened up and asked questions which they did not ordinarily ask in the clinic. These visits also created opportunities for one-to-one interaction and for health workers to provide caregivers with information on both vaccination and other child survival strategies. However, few caregivers mentioned home visits and outreaches conducted by health workers as important and useful. Health workers and caregivers agreed that the media was an important vehicle for delivering communication messages (radio in rural settings and television and radio in urban settings). However, text messages and phone call reminders were less popular among health workers due to their experiences of having to fund these from their personal monies.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. A comparison of health workers’ and caregivers’ views regarding preferred sources of childhood vaccination information.

https://doi.org/10.1371/journal.pone.0186733.t002