|In Jega township on 31 July 2011 during IPD rounds, a caregiver brings a child missed during a previous IPD round to receive the necessary dose of OPV.|
By Abhijit Shanker
4 October 2011 - Nigeria remains one of the world’s four remaining polio endemic countries - along with Afghanistan, India and Pakistan. Nigeria is still battling to end the transmission of the wild poliovirus, but children and households continue to be missed, especially in northern Nigeria. In an effort to solve this challenge, an innovative Household Adoption (HHA) strategy was created, which engages local women in conducting a micro-census of eligible children before campaigns. Using the data they have collected, they also “adopt” the household, and guide vaccinators on how best to immunize all registered children during campaigns. The idea was based on the assumption that, if all eligible children in all households within a settlement/village are recorded by name and age prior to an immunization exercise, such data in the hands of the local community could be used to better guide immunization. No child, except one born after the census, would be at risk of being missed during a campaign. As a result, of the micro-census, children are now easily traced and vaccinated. The HHA strategy creates local ownership of the problem. By knowing the number, names and ages of missed children, they can now be revisited if missed, and thereby immunized against polio. In addition, wastage is also reduced so that more oral polio vaccine (OPV) doses are available for more children.
For the first time since reliable surveillance commenced in Nigeria, Type 1 wild poliovirus (WPV1) transmission in very high and high risk (HR) states has declined to the lowest-ever recorded levels. The Polio Eradication Initiative (PEI) in Nigeria depends heavily on advancing the engagement of political and traditional leaders, especially at the local government area (LGA) and ward levels, and on improving the quality of Immunization Plus Days (IPDs) to ensure that every eligible child is reached.
The adoption of more strategic approaches in recent years has enhanced political leaders’ ownership, commitment and oversight of PEI activities particularly at state and LGA level; generated more systematic engagement of traditional leaders in PEI activities; improved the quality of supplemental immunization activity (SIA) operations including the micro-planning, supervision and use of flexible strategies; and created community demand for immunization including supporting efforts to improve routine immunization. It has also prioritized the provision of technical assistance necessary to support high-quality SIAs, primarily in communication, advocacy, social mobilization, vaccine security and logistics.
UNICEF’s leadership of polio communication activities has focused on implementation of the recommendations of the Expert Review Committee (ERC): strengthening national, state and LGA structures to effectively plan and implement communication activities; forging partnership with and building the capacity of community groups; increasing the use of data for communication planning; and developing information, education and communication (IEC) tools and materials to promote public education and sensitization.
Non-compliance (vaccine refusals) still makes up a considerable proportion of all missed children, but the refusal rate is on the decline. The Intensified Ward Communication Strategy (IWCS) - a highly localized, evidence-based communications planning and action approach on which numerous innovative interventions are based - is believed to be playing a key role. It uses social data to engage communities and target messages to address specific reasons for refusal, including low polio threat perception and doubts about oral polio vaccine (OPV) safety and efficacy. The IWCS isolates HR wards based on campaign performance indicators and prescribes a package of communication interventions that rely heavily on interpersonal contact. These interventions embody a range of approaches that are being implemented to reach HR populations.
Among the pilot approaches experiencing success is HHA, whereby commissioned volunteers “adopt” 25 to 50 households and track and record immunization rates for all individuals residing in those homes. This case study examines the efficacy of HHA in advancing the goal of making Nigeria polio free.
HHA was first piloted in Kalgo LGA in Kebbi State during the June 2011 IPD, after which the successful pilot was scaled up in July 2011 for use in eight HR LGAs in Kebbi during IPDs. Only 11 of 3,287 children were missed due to noncompliance, and those children could be identified by name and age.
The strategy was cost effective. The record of children serves as a map to reaching them all, which can be updated before every campaign round as children are born, or die. The number of pregnant women in each settlement could also be recorded at the same time so that a follow-up vaccination could be conducted either by re-visitation or routine immunization.
Strategy and Implementation
The objectives of the HHA strategy are to:
>> Vaccinate every last child by name and age
>> Check and control missed/absent children in HR settlements
>> Update target household population records.
Approach / methodology: Household adoption employs a house-to-house (H2H) process and engages school teachers, members of the community or PEI influencers - typically women based in high risk settlements – as volunteers to first perform a micro-census of all eligible children in 25 to 50 adopted (assigned) households within a settlement or village. Their goal is to track all eligible children in those households over repeated immunization campaigns. They record the names of the head of household, spouses and eligible children and their ages in notebooks a week before an immunization campaign commences.
During campaigns, the HHA team collaborates with vaccinators who visit their adopted households in order to ensure that all children in those households are immunized. Absent children are identifiable by name so that a returning vaccination team can identify each child missed during the previous round.
Advocacy & Social Mobilization: HHA uses the H2H mobilization approach to support Polio Eradication Initiative (PEI) activities before and during SIAs. Targeted message dissemination ensures that all eligible households are informed about polio and immunization and that all eligible children are registered and immunized.
Measurement and evaluation (M&E) systems: The HHA strategy facilitates the improvement of data quality in order to achieve 100 percent coverage. Although the innovation is in the initial stage of implementation, the system is in place to measure this outcome. The monitoring checklist has a user-friendly format that includes a column where the immunization status of all children is recorded. Monitoring takes place concurrently with community engagement by health educators at LGA level and at ward level.
The preparation process for implementation of the HHA strategy incorporates three steps:
Step 1: Identify HR areas / number of households
Step 2: Identify and recruit literate women as volunteers to conduct the campaign
Step 3: Train volunteers on using the reporting tool and on house marking, and assign households.
A few days prior to a campaign, selected HHA volunteers are provided with reporting tool templates (see sample below) to record the names of household head, spouses and eligible children in identified HR settlements, as well as summary comments, in a notebook. They are provided one day of training, which includes use of the template, house marking (to indicate houses where census was conducted), IPC (interpersonal communication) skills and field practice. Next, they pilot a micro-census across a limited number of households in identified settlements and make advocacy visits to stakeholders in those settlements. The purpose of this strategy is to prepare volunteers to track all eligible children in adopted households.
See Reporting Tool Sample
During implementation, the HHA teams work with the immunization teams to ensure that all children in all households are immunized. Absent children are identified by name, which allows revisiting teams to pinpoint missed children. At the end of implementation, the HHA team supervisor collects and hands over all HHA records to the LGA Health Educator, who compiles and forwards a summary to the state Health Educator, who in turn analyses and shares the data.
Progress and Results
In accordance with the Expert Review Committee (ERC) recommendations to concentrate advocacy and innovations on the most underserved, the UNICEF team in Kebbi replicated the best HHA practices to minimize missed children in 20 key settlements across eight HR wards/LGAs where missed children and WPV were present. The HHA strategy contributed remarkably to increasing coverage of missed children to 100 percent in these settlements, as reflected in data from 18 settlements (see table). In all, 988 households containing 3,287 eligible children were covered; of these, only 11 children were missed in two settlements due to non-compliance. The HHA strategy was implemented by 36 personnel, who were paid N1000 each (N500 for conducting the pre-implementation micro-census and N500 for implementation).
See table and chart reflecting the success of the innovation in the Kebbi trials and its usefulness in addressing operational issues of team performance.
During the initial micro-census, visiting children found in some households were miscounted and included in the reports. Furthermore, some households were missed, notably in compounds that had multiple households (assuming a household comprises a husband and members of his immediate family). Finally, there was some initial difficulty convincing literate women in some identified settlements to participate in the Household Adoption strategy, due to the programme’s novelty and limited funding.
It was clear that if the micro-census could be conducted successfully, all eligible children in all households in an entire settlement - except those born soon after it - would be immunized, so care was taken to ensure the thoroughness and clarity of the survey and reported data. The ability to update the census on subsequent visits also facilitated both accurate reporting and complete coverage.
The census could include pregnant women within households and their expected dates of delivery, information that could be made available to health facilities/hospitals, thereby improving health/birth outcomes, as not all women in rural areas seek ante-natal care.
The census could also assist in determining the exact target population of under five and pregnant women in particular periods of time.
Household Adoption is a new concept. The key differentiator and benefit of the programme is that through engaging local women in collecting data on the immunization status of children, they can guide immunization teams to record unimmunized children by name and age in each and every household, with unprecedented improvement in immunization coverage.
In addition to tracking immunization histories and ages of family members in each household, the HHA census could:
>> Maintain birth and death records for each household
- Record potential causes for death records
- Track clinic visits and/or morbidity under age one
>> Assist general surveillance of illness within households
- Report to the Health Facility during outreach or monthly meetings
- Identify and report acute flaccid paralysis (AFP) cases
>> Support Routine Immunization (RI)
- The household adopter could be engaged as the contact point in between eligible household and health facility in order to strengthen routine immunization in the health facility.
>> Provide reliable census data to village health facilities for planning, e.g., for routine immunization of village children and for mobilization of pregnant women for antenatal care.
The HHA team plan to share the census data and the HHA strategy paper with the UNICEF Line Manager and colleagues and with WHO in Kebbi state, for reference, during the October 2011 IPD in all high risk wards.
With high-level advocacy, states could be encouraged to fund the Household Adoption strategy as a way of immunizing every last child. Coverage rates of over 90 percent of women and children by health-related services could potentially be achieved by aligning the performance of HHA micro-censuses with scheduled IPDs.