Increasing immunisation in Ogun State, Nigeria: a formative evaluation of a participatory action research intervention
3ie evidence programme: Innovations in Increasing Immunisation Evidence Programme
Author(s): Ngozi Akwataghibe, Elijah Ogunsola, Oluwafemi Popoola, Adanna Emeji, Marjolein Dieleman
Institutional affiliation(s): Royal Tropical Institute, Amsterdam; Ogun State Primary Health Care Development Board, Nigeria; University of Ibadan, Nigeria
Grant-holding institution: Royal Tropical Institute Amsterdam
Main implementing agency: Ogun State Primary Health Care Development Board, Nigeria
Sex disaggregation: Yes
Gender analysis: Yes
Equity focus: Yes
In 2005, Nigeria adopted the Reach Every Ward strategy to improve vaccination coverage for children 0-23 months old. By 2015, Ogun State in the southwestern region had achieved full immunisation coverage in 12 out of 20 of its local government areas (LGAs). However, the remaining areas continued to face barriers to achieving full immunisation coverage, with the highest proportion of unimmunised children belonging to the Remo North LGA. The participatory evaluation and participatory action research (PAR) approach was introduced to provide context-specific solutions to increase immunisation coverage in Remo North.
The intervention used the PAR approach to identify community-related factors that hinder immunisation coverage and find contextually relevant solutions to problems. It identified the needs and expectations of communities with respect to immunisation services for infants and children, matched services to those needs, as well as to the expectations of health workers and the local government. This was done by putting together a contextually relevant joint action plan. The PAR commenced with a baseline study (situational analysis) using both quantitative and qualitative methods. The situational analysis informed the first round of dialogue among health workers, community members and the local government to develop a joint action plan, which was implemented over four months. Researchers then assessed progress, which informed a second round of dialogue. The participants developed a second joint action plan, which was again implemented over four months.
The PAR approach focused on collaboration among the community members, health workers and the local government as a way of engaging local people in decisions concerning them. This approach rested on three key assumptions:
- The communities, local governments and health workers would actively participate in the process and take ownership. This would enable the development and implementation of contextually relevant solutions to address the identified barriers to immunisation uptake.
- Different groups in the community would be able to voice their views openly regarding immunisation services, and their views would be heard by health workers and the local government.
- This approach would build and improve the capacity of the local government and health workers, and enable them to improve the delivery of health services.
Evaluation design and methodology
This study was carried out in Ipara and Ilara wards in the Remo North LGA, Nigeria. These two were the best and worst performing wards in terms of immunisation coverage. Quantitative methods included a household survey targeted at caregivers, a secondary analysis of the National Health Management Information Systems data, and a cost-effectiveness analysis of the PAR approach. Qualitative methods included in-depth interviews and focus group discussions with policymakers, local government officials, community leaders, health workers, PAR participants and community members. During baseline, the research team conducted a gender analysis to discern how gendered power dynamics affect household decision-making on immunisation.
Primary evaluation questions
This study answers the following questions:
- What is the effectiveness of the PAR approach in relation to improving immunisation coverage in the Remo North LGA?
- How efficient was the PAR approach in the delivery of the Reach Every Ward strategy in the intervention areas?
- What lessons have been learned in using the PAR approach to improve immunisation services for Nigeria?
- Does the PAR approach present opportunities for a sustainable solution to immunisation access, utilisation and coverage in Nigeria?
The PAR process was successful in helping the community in Ilara gain access to health services. Through this intervention, the community was able to revitalise the Ilara healthcare facility, which meant that the community members no longer had to travel to Ipara to avail health services.
An assessment of the health management information system data indicates that immunisation coverage in the Ilara ward increased from 26 to 59 per cent. For Ipara, coverage for all the antigens except measles remained high. The significant decline in measles coverage was ascribed to persisting cultural barriers and the reduction in clientele to the Ipara healthcare facility due to revitalisation of the healthcare facility in Ilara.
An analysis of the wealth quintile data collected indicates that children from poor households were 1.58 times more likely to be fully immunised than children from poorest households. The qualitative data indicates that men were primary decision makers about who gets vaccinated within the household, as well as in the community. Decisions taken by women, including whether or not to immunise their children, had to be approved by men. During the focus group discussions, participants brought up issues regarding adverse events following immunisation (AEFI). They expressed that most people in the communities know the importance of immunisation and yet some people refused to have their children immunised due to fear of adverse reactions. However, due to community mobilisation as per the PAR action plan, there was increased sensitisation towards immunisation and its benefits in the community. A high proportion of caregivers
had changed their perceptions about AEFI. The increased awareness, particularly in the Ilara community, led to a decrease in fear among the community members about AEFI.
A limitation of this study is that the PAR could not change major flaws in the system. For instance, the governance arrangement around the health system was outside the influence of this approach. Additionally, some contextual elements like health staff strikes and high turnover were outside the control of the PAR.
The authors recommend a full impact evaluation, with careful attention to design and a counterfactual, so as to ascertain the effectiveness of the PAR intervention and its replicability.