RESEARCH ARTICLE Open Access

Factors affecting the implementation ofchildhood vaccination communicationstrategies in Nigeria: a qualitative studyAfiong Oku1, Angela Oyo-Ita1, Claire Glenton2, Atle Fretheim2,3, Glory Eteng4, Heather Ames2, Artur Muloliwa5,Jessica Kaufman6, Sophie Hill6, Julie Cliff7, Yuri Cartier8, Xavier Bosch-Capblanch9,10, Gabriel Rada11

and Simon Lewin2,12*

Abstract

Background: The role of health communication in vaccination programmes cannot be overemphasized: it hascontributed significantly to creating and sustaining demand for vaccination services and improving vaccination coverage. InNigeria, numerous communication approaches have been deployed but these interventions are not without challenges.We therefore aimed to explore factors affecting the delivery of vaccination communication in Nigeria.

Methods: We used a qualitative approach and conducted the study in two states: Bauchi and Cross River States innorthern and southern Nigeria respectively. We identified factors affecting the implementation of communicationinterventions through interviews with relevant stakeholders involved in vaccination communication in the health services.We also reviewed relevant documents. Data generated were transcribed verbatim and analysed using thematic analysis.

Results: We used the SURE framework to organise the identified factors (barriers and facilitators) affecting vaccinationcommunication delivery. We then grouped these into health systems and community level factors. Some of the commonlyreported health system barriers amongst stakeholders interviewed included: funding constraints, human resource factors(health worker shortages, training deficiencies, poor attitude of health workers and vaccination teams), inadequateinfrastructure and equipment and weak political will. Community level factors included the attitudes of communitystakeholders and of parents and caregivers. We also identified factors that appeared to facilitate communication activities.These included political support, engagement of traditional and religious institutions and the use of organisedcommunication committees.

Conclusions: Communication activities are a crucial element of immunization programmes. It is therefore important forpolicy makers and programme managers to understand the barriers and facilitators affecting the delivery of vaccinationcommunication so as to be able to implement communication interventions more effectively.

Keywords: Communication strategies, Vaccination, Nigeria, Barriers, Facilitators, Qualitative study

BackgroundGlobally, vaccination is recognized as a cost-effective pub-lic health measure for decreasing childhood mortality andmorbidity [1]. Strategies which improve the uptake ofvaccination include ‘supply-side’ interventions, such as en-suring a constant supply of potent vaccines, strong health

systems to ensure delivery of these vaccines and sufficienthealth personnel to administer vaccines [2]; and ‘demand-side’ components which focus on individual and house-hold determinants of health-seeking behaviours, such asbuilding the knowledge base of individuals to utilisevaccination programmes to their advantage. Addressingvaccine hesitancy linked to parental knowledge, under-standing, attitudes, beliefs, and behaviours is an importantexample of a demand-side component [3–9].Poor communication, if not addressed, can undermine

several components of vaccination delivery, including

* Correspondence: simon.lewin@fhi.no2Norwegian Institute of Public Health, Postboks 4404 Nydalen, 0403 Oslo,Norway12Health Systems Research Unit, South African Medical Research Council,Francie van Zijl Drive, Parowvallei, PO Box 19070, 7505 Tygerberg, South AfricaFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Oku et al. BMC Public Health (2017) 17:200 DOI 10.1186/s12889-017-4020-6

vaccine acceptance [3]. Improving vaccination commu-nication delivery is therefore crucial to achieving bettervaccination outcomes [10, 11] as well as the greater goalof knowledgeable caregivers and communities – import-ant contributors to improving child health in many set-tings [12–14]. Effective communication could improveuptake of childhood vaccination, address incompletevaccination or missed children, further strengthenroutine immunization programmes, and encourage theuse of new and underused vaccines. Although communi-cation is an invaluable tool in routine and campaignchildhood vaccination activities, as well as in otherhealth programmes, it is rarely addressed in a systematicway compared with other components of vaccinationprogrammes [3]. Ideally, vaccination communication ef-forts should complement and boost other immunizationcomponents, such as service provision, quality of care,capacity-building and the skills of health personnel, anddisease notification and surveillance [15].In Nigeria, where this study was based, routine vaccin-

ation coverage for all recommended vaccines hasremained poor though there has been a gradual rise invaccination coverage from 21% of eligible children (0–11months of age) in 2003 to 25% a decade later [16].Factors seen to have contributed to poor routineimmunization performance include ineffective supplychains, poor delivery of services, scarce humanresources, low demand for health services, funding gaps,accountability issues and weak governance, and poordata quality [17]. Furthermore, vaccine hesitancy – de-fined as “a delay in the acceptance or refusal of vaccinesdespite the availability of vaccine services” [18] – mayalso play an important role. Vaccine-hesitant individualsare a mixed group: individuals may delay receiving vac-cines, or may agree to vaccines but be unsure of doingso, or may decline some vaccines but agree to others, ascommonly observed in some parts of northern Nigeriain the context of oral polio vaccine mass campaigns [13].For example, studies have shown that the increasednumber of polio campaigns in Nigeria were seen as sus-picious by some populations [19, 20].Communication interventions have made significant

contributions to the polio eradication programme inNigeria [21]. Numerous communication interventionshave been implemented, particularly in high-risk statesfor polio, with the aim of increasing acceptance ofroutine immunization and breaking the transmission ofwild poliovirus. However, implementing these communi-cation interventions has been challenging. This paperaims to explore factors affecting the delivery of vaccin-ation communication in Nigeria. An understanding ofsuch factors can inform policy makers during the plan-ning of communication interventions and when adaptingthese to suit local contexts. This study forms part of the

‘Communicate to vaccinate’ (COMMVAC) research pro-ject which focuses on building research evidence to im-prove communication about childhood vaccinations withparents, caregivers and communities in LMICs. In thisstudy, communication interventions refer to all interven-tions which are purposeful, structured, repeatable andadaptable strategies aimed at informing and influencingindividual and community decisions on personal andpublic health participation, disease prevention andpromotion, policy making, service improvement andresearch [12, 22].

MethodsStudy settingThe setting for the study was Nigeria, the fourteenth lar-gest country by landmass in Africa, with a projectedpopulation of over 180 million people in 2016. Nigeria isdivided administratively into 36 States and the FederalCapital Territory (FCT) Abuja. Each State is furtherdivided into Local Government Areas (LGAs), which aremade up of several wards. The Nigerian people havediverse cultures, religions and ethnicities.In Nigeria, the agency responsible for controlling

vaccine-preventable diseases through the provision ofvaccines and immunization guidelines is the NationalPrimary Health Care Development Agency (NPHCDA).National responsibility for the development of commu-nication interventions for vaccination programmes isgiven to the National Social Mobilization WorkingGroup, while State and Local Social MobilizationCommittees are responsible for coordination and imple-mentation of communication interventions at the Stateand Local Government levels. The routine immunizationschedule in Nigeria recommends that all childhood vac-cinations are completed by nine months of age. Inaddition to routine immunization, numerous rounds ofmass campaigns are also held in all the states of thecountry as part of efforts to eradicate poliomyelitis.Campaigns are also carried out occasionally for menin-gococcal meningitis, measles and yellow fever vaccines.

Study sitesWe conducted the study in rural and urban settings ofBauchi and Cross River States in northern and southernNigeria. We also conducted interviews with national-level decision makers in Abuja, the capital city. Weselected Bauchi and Cross River States based on differ-ences in vaccination coverage rates, with lower rates inBauchi compared to Cross River (DPT3 coverage ratesof 12.5 and 76.1% respectively) [16]; and differences interms of vaccine hesitancy, with vaccine refusal beingmore common in Bauchi, related to religious and cul-tural beliefs [23]. Bauchi was selected over Borno andYobe States in northern Nigeria, which recorded the

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lowest vaccination rates in the country, as security issuesin those two states made research difficult. In addition,at the time that the study was conducted in 2014, Bauchiwas among the 12 polio prevalent states of northernNigeria and has received both global and national atten-tion to eliminate polio and improve vaccination uptake,with appreciable resources directed to vaccination com-munication activities. Cross River State was selected toprovide an example of a good performer in terms of vac-cination coverage, with vaccination coverage second onlyto Rivers State (52.5 and 55.5% respectively) [16]. CrossRiver has received less national and international atten-tion than Bauchi and has maintained polio-free statusfor over a decade. Lastly, the religious settings of thetwo states are different: Bauchi is predominantly Muslimwhile Cross River is predominantly Christian. Thesedifferences in religious beliefs may impact on beliefsabout and attitudes towards vaccination.

Study designThe study used a qualitative approach, based on datafrom key informant interviews.

SamplingWe purposively selected stakeholders involved in vaccin-ation activities and who played active roles in the planningor implementation of childhood vaccination communica-tion strategies at different levels of health care delivery,and who had the potential to provide rich, relevant and di-verse data pertinent to the study objective. These stake-holders included policy makers, programme managers,social mobilization officers/health educators and represen-tatives from relevant organizations including UNICEF, theWorld Health Organization and the Vaccine Alliance(GAVI). We conducted a total of 15 interviews (Table 1).

Data collection methodsData collection took place from January to April 2014. Weused a semi-structured interview guide (Additional file 1)

to gain insights into the factors affecting the implementa-tion of communication interventions in Nigeria. The inter-view team comprised the principal investigator (AO) asmoderator and a note taker who took down notes of bothverbal and non-verbal responses. The interviews werecarried out at a convenient time and place chosen by therespondent, were conducted in English, and lasted30–45 min on average. We recorded each interview sessiononce informed consent had been sought and obtained. Atthe end of each interview, we transcribed the recorded ses-sions verbatim and placed them in a file bearing the datethe interview was conducted, the place and the researchquestions that the interview addressed. We tried to ensureanonymity as far as possible but because many respondentsheld very senior positions, it was difficult to ensurecomplete anonymity. All data files were securely stored.

Data analysisTwo researchers (AO and GB) carried out data analysisusing a framework thematic analysis approach [24, 25]which involved four steps: familiarization, indexing/cod-ing, charting and mapping/interpretation. First, we fa-miliarized ourselves with the data collected by listeningrepeatedly to the audio recordings and studying thetranscripts. This helped us gain an overview of the bodyof material gathered and to become aware of key ideasas well as recurrent themes. Our next step was toidentify portions of the data that corresponded to aparticular theme (indexing or coding). To enhance thevalidity of the coding, the principal investigator (AO)and a sociologist (GB) from the University of Calabarcoded the data and each developed a coding book. Wethen coded each interview transcript independently andlater merged our findings. We went through each inter-view transcript and extracted information on possiblefactors affecting the implementation of childhood vac-cination communication interventions. The SURE(Supporting the Use of Research Evidence) Framework,a theory-informed conceptual framework, offered us auseful starting point for our analysis as it provided uswith a comprehensive list of possible factors that couldinfluence the successful implementation of interventions[26]. We identified a number of themes when lookingthrough the data, which we then organised under differ-ent categories and sub-categories, drawing on the SUREFramework (Additional file 2). Financial constraints,health resources, inadequate infrastructure and equip-ment were grouped in the ‘health system constraints’domain; issues related to politics were grouped in the‘social and political’ domain; while community level fac-tors brought together the SURE framework domains of‘recipients of care’ and ‘providers of care’.Thereafter, we lifted the indexed data from its original

textual context and put these data in charts that

Table 1 List of stakeholders interviewed

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 Riverand 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

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organized the themes into categories and sub-categories.Interesting data extracts and central themes were usedverbatim to illustrate key findings. As themes emergedthese were indexed and compared with themes fromsubsequent interviews. Lastly, we did a mapping andinterpretation which involved the analysis of the keycharacteristics as laid out in the charts.

ResultsThe factors we identified were grouped into three sub-categories: health system level factors, political factorsand community level factors.

Health system factorsFinancial constraintsIn both states, all respondents interviewed at the differ-ent levels of the health care system consistently men-tioned that inadequate funding was the main barrier tothe implementation of vaccination communicationinterventions. However, this concern was expressedmore strongly in Cross River than in Bauchi. While oneof the respondents confirmed that poor funding hadbeen found to disrupt all aspects of the vaccinationprogramme, he also pointed out that communication isusually worse hit, with the smallest allocation, or oftennothing, for routine immunization. The respondents re-ported that funding gaps led to poorly implementedcommunication activities in terms of coverage and fre-quency of messaging.Most respondents noted that communication inter-

ventions for mass campaigns generally receive signifi-cantly more funding and resources than routineimmunization programmes. This gap was attributed bymost respondents to the absence of donor or partner in-volvement in communication activities, especially forroutine immunization activities, which donors viewed asthe responsibility of the government. Some respondentspointed out that communication activities around rou-tine immunization were particularly limited in frequencyand range. This, they suggested, was due to the fact thatcommunication activities were not specifically budgetedfor in routine immunization programmes, which wasevident from an absence of communication interven-tions between campaigns. Some respondents, however,argued that communication activities were generallyunderfunded for both campaigns and routineimmunization activities and were never given priority at-tention when immunization programmes were planned.A national stakeholder commented:

“In October 2012, when we had a campaign formeningitis, Nigeria’s communication budget for thatcampaign was only two percent of the total budget forthe campaign and yet we expect miracles to happen.

Same way, if you look at the communication budget inother programmes, I’m sure you will be shocked to seethat communication always receives the least budget.So, if this does not change – because one thing incommunication is that what you give in is what youget out and communication is not something you doonce and you stop.” (Decision maker, national level)

Campaigns only received the desired attention amongthe public, they stressed, if communication was on thepriority list for funding by development partners anddonor agencies. The overdependence of states and localgovernments on the federal government to fund com-munication activities also further contributed to theproblem.The effects of the funding gap for vaccination commu-

nication were felt most at the local government and statelevels with responsibility for delivering communicationinterventions, and played out in two ways. Firstly, somerespondents at the state level reported late release offunds for communication activities. This was observedto delay disbursement of needed materials (printed post-ers and other information, education and communica-tion materials), especially to hard-to-reach areas.Secondly, at local government levels, the local mobili-

zers confirmed that funding gaps contributed to delaysin implementing activities and sometimes to a failure toimplement these activities at all. Respondents citedinstances when materials produced for particular cam-paigns arrived at the local government late, at the end ofthe campaign, or not at all. This occurred because fundswere not readily available to transport these materials tothe local government areas. In some cases, materialsremained in storage at the state level and were not dis-tributed to local government areas.Respondents also described accountability issues,

with funds earmarked for communication activitiesoccasionally being diverted to address other pressingneeds, further delaying the implementation of com-munication activities, particularly as local funding wasdifficult to access. This was more commonly reportedin Cross River than in Bauchi. Funding constraintswere sometimes cushioned by development partnerswho provided funds for specific activities duringcampaigns in some local government areas. Healthworkers, especially those at the local government level,tried to solve the issues related to funding delays by usingtheir personal monies and private vehicles to meet theirtargets for monthly routine activities in their respectivelocal government areas:

“In terms of funding, especially for campaigns, fundsare provided but it is never enough for our plannedmobilization activities. This affects the range of

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activities one performs. Most times, we have to use ourown funds to succeed. If you want a wider coverage,they may give you funds for a specific number but youmay go out of your way to reach more people.”(Mobilization officer, Cross River State)

“I use my salary now to do my activities, especially forroutine immunization activities, to meet up and beable to present my report at the State meeting.”(Local social mobilization officer, Bauchi)

Inadequate infrastructure and equipmentSome respondents at the state and local levelshighlighted the fact that the basic requirements to con-duct an effective and extensive community mobilizationfor vaccination were not readily available. The statemobilization unit, which coordinates communication ac-tivities at the lower levels, lacked well-equipped offices,computers, vehicles and motorcycles or other means oftransportation. Other equipment needed for these activ-ities were not readily available such as megaphones, pub-lic address systems used for announcements and printedcommunication materials such as flyers, leaflets andposters:

“A lack of mobility is a major challenge. Youdefinitely cannot carry out an effective socialmobilization work without mobility because youneed to cut across many places. We do not haveany vehicles attached to this department.”(Mobilization officer, Cross River State)

Human resource factorsHealth worker shortages Most respondents at thestate and local levels in both states referred to thegeneral shortage of health personnel, especially inrural areas where more than 70% of the populationreside. This deficit in human resources affected thedelivery of vaccination communication and theimmunization programme as a whole. Health workershortages affected rural areas particularly, wheresome health facilities had only one health worker re-sponsible for the various tasks in the vaccinationclinic such as registration of clients, conductinghealth education sessions and administration ofvaccines.

“Every health worker wants to work in the urbanareas, especially those whose husbands are politicians,and every big man wants his wife to be in the urbanarea. So when you transfer them it’s a big problem.This has resulted in many of them in the urban andvery few health workers in the rural areas.”(Immunization Officer, Cross River State)

Respondents in Bauchi noted that this gap was partlyaddressed through the use of volunteer communitymobilizers, and the use of traditional and religiousleaders as community mobilizers.

Training deficiencies While some respondents alludedto the fact that there was an organised structure to man-age communication activities at the national, state andlocal levels, other stakeholders pointed out that the struc-ture on the ground did not translate into having qualifiedpersonnel at the community level to meet the objectivesof the immunization programme. They highlighted thelack of well-trained communication personnel as a barrierto the effective mobilization of communities, especiallythe lack of personnel at local levels. They observed thateven after training, personnel at the local level may not beable to meet the desired objectives of the programme ef-fectively because of a lack of proper supervision and mon-itoring at this level. One of the respondents noted thatfailure to see the need to train and prepare these healthworkers to effectively deliver vaccination communicationmessages was related to the fact that they were under theresponsibility of the local government, not the State Min-istry of Health. This meant that the state had no con-trol over the local government health workers anddid not see these health workers as their responsibil-ity. He further explained that the local governmentusually depended on the State Ministry of Health tosupervise and monitor the health workers at thelower levels, but this rarely happened. One respond-ent was also of the view that health workers had poorcommunication and negotiation skills and were notable to communicate the purpose of their visit well,especially when they visited resistant households.This, the respondent noted, may have contributed totheir poor performance in the field.Another respondent described how the ‘cascade’

model of training was partly responsible for the train-ing gap. He explained that before a campaign, statesocial mobilization officers or health educators aretrained directly by the national level to deliver train-ing to the local Social Mobilization officers. The localSocial Mobilizer is then expected to train “unqualifiedcommunity members” at the ward level. The respond-ent described how dilution occurred, with the qualityof the training declining at each stage, leading topoor training outcomes:

“You will find out, especially at the local governmentlevel, that the local Social Mobilizers who are saddledwith communication assignments are not trainedcommunication personnel. So you end up training andtraining and training. Some people are not justtrainable.” (Development partner)

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Poor attitudes of health workers and vaccination teamsPoor attitudes among health workers at the state andlocal government levels and a lack of commitment to so-cial mobilization activities outside campaigns were alsoreported to impact negatively on communication inter-ventions for vaccination programmes. For instance, insituations where there was a delay in funding at the na-tional level, respondents reported that mobilizers wouldnot begin mobilizing the communities in which theyworked but would instead wait for the funds to be dis-bursed before initiating mobilization activities. This wassaid to have led to poor performance by these vaccin-ation teams in terms of achieving vaccination coverageoutcomes. The reasons behind this may be healthworkers’ previous experiences of not being paid or beingunderpaid for services rendered or having to use theirown resources to conduct communication activities, withreimbursement often being delayed. Respondents alsostressed that many of the vaccinators were not committedto meeting the objectives of the programme but were in-stead interested in what they stood to gain financially.

Political factorsMost respondents viewed the presence of politicalsupport as a major facilitator while the absence ofpolitical support was seen to undermine the deliveryof health interventions. They noted that communica-tion interventions for routine immunization would bemore likely to achieve their objectives if they weregiven similar levels of political support to that givento campaigns. Political support for mass campaignsvaried across states and local governments and tendedto be stronger in high-risk states or local governmentareas which had national or international attention orwhere political leaders were given mandates to im-prove their vaccination coverage, as we describe inmore detail below.

Failure of state and local governments to own the vaccinationprogrammesSome development partners involved in the implementa-tion of communication interventions noted that moststate and local political leaders failed to show ownershipof the immunization programme. This was more of aproblem in the southern states compared to the North,which enjoyed more donor support. The developmentpartners noted that political leaders failed to providefunds to carry out communication interventions in theirstates or local government areas or failed to disbursethese funds in a timely manner or to train and deployhealth staff and provide the materials and equipmentneeded to effectively deliver routine vaccination services.The reason given by some respondents included anover-dependence on development partners and the fact

that political leaders are usually more interested in com-mitting their resources to more visible infrastructure,such as roads and schools. One of the partners reportedthat only a few states he had worked in had demon-strated ownership of programmes and taken the lead inproviding the necessary funds and making decisions:

“If the states and the local government own thisprogramme, you don’t need money from partners. Forinstance, a state that owns a radio station, a televisionstation, you see all these stations should have beenrunning free jingles. But they never do that. If youwant to run anything, they ask you to pay even if it istheir own children and mothers that will benefit. Ifthere is ownership, those things will not happen, it isonly once in a while in some States during campaignsyou see them giving those orders. Immediately after thecampaign, announcement stops.”(Development partner)

“At the national level the states are asked to developtheir communication interventions and thereafter theydon’t have money to implement, and expect fundsfrom the national to implement this and that hardlyhappens except for the funding that UNICEF sendsbecause UNICEF is the mandate agency for poliocommunication.” (Development Partner)

“We, the partners, are running after the government insome states whereas in other states, even when you gothere and take over the driver’s seat, it is still almostimpossible to drive the government to follow you andyou can’t be at the forefront of any programmebecause the communities will still not see you as oneof theirs. They hardly ever have enough funds toimplement communications activities in the context ofhealth programmes.” (Development Partner)

Health communication interventions not a priority amongpolicy makersMost respondents reported that while most policymakers were inattentive towards health issues in general,this also applied to health communication which wasviewed as a sort of “optional add-on” to the array ofhealth workers’ tasks. Respondents argued that healthcommunication, whether for routine or mass campaigns,was usually perceived as a minor service component andwas not seen as important or necessary. One of thefactors contributing to this problem seemed to be theassumption by policy makers that health care workersdo not require any training in communication skills butdo require more training on technical components ofthe immunization programme. Some respondentsreported that the level of funding allocated to

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communication activities demonstrated the perceivedlack of priority, as discussed above. This attitude towardscommunication activities, they explained, trickles downto all levels of government and results in health commu-nication not being given the attention it needs, as one ofthe respondents noted:

“In our national budgeting, health is not one of thoseareas that attract funding. Even when immunizationis considered, the funds allotted are usually for othertechnical components and communication is rarelyconsidered and this trickles down to the localgovernment level. Because if the national governmentdoes not allocate adequate resources to health orcommunication, the states will not see any reason todo that, so this now boils down to who is in charge. Ifthe person in charge does not have an interest inhealth, then health is treated as unimportant.”(Development Partner)

Community level factorsAttitudes of community stakeholdersRespondents also discussed the attitudes of commu-nity stakeholders in certain communities. One re-spondent reported that in some rural areas,community members demand money from healthworkers in exchange for immunization services evenwhen they understand the benefits of the programme.This, they suggested, was because community mem-bers believed that health workers were paid well tobring the services to them. In some instances, com-munity gatekeepers were also reported as having pre-vented campaigns from being organised in theirsetting and having insisted that government providebasic necessities such as accessible roads, schools andhealth services before these campaigns could takeplace. This occurred rarely in some communities butwas more often seen in hard-to-reach areas wherepeople felt marginalized:

If you go to the community now they believe youcame with money to give them. If you don’t givethem they will sabotage your activities so that iswhy we have problems. Because you need people tocome and get immunization sometimes we have togive them some incentives before they help indelivery of vaccination messages. I had anexperience in the past when you go into thecommunity, they say to you, “You people areenjoying yourselves under air-condition and drivingbig cars and yet we are suffering”. So once you givethem something they cooperate with you and takethe messages to their communities.”(Senior Health officer, Bauchi)

Attitudes among community membersSimilar issues were raised by respondents across the twostates. As expected, vaccine resistance was more frequentlyreferred to by respondents in Bauchi than in Cross RiverState and respondents reported that this tended to affectnegatively the reception of communication messages. InBauchi, this resistance was particularly seen in response topolio campaigns. One reason given by respondents was thelarge number of polio campaigns which they suspectedhad led community members to believe that the govern-ment was concentrating its resources on polio whileneglecting their felt needs. In addition, certain religiousgroups and anti-polio vaccine campaigners have spreadrumours about the inclusion into the vaccine of anti-fertility drugs or the HIV virus, as way of checking popula-tion growth in Muslims. In Cross River, respondents re-ported that pockets of resistance existed among certainreligious groups in some communities.

“Refusals of polio vaccine still persist in somecommunities. There is a video tape being circulated byone Muslim teacher discouraging people againstvaccination which led to a lot of rejections of the poliovaccine and resulted in our vaccination teamsembarking on house-to-house immunization to beattacked because of the tape”(Local Social Mobilizer, Bauchi)

“People are very hesitant when it comes toimmunization campaigns, and have a phobia forpolio campaigns in this part of the country. That iswhy our most important problem is this one. Evenwhen people have heard about the campaignsthrough radio messages and are aware of it, theyare still sceptical about immunization campaignsgenerally. People accept routine immunization butthe campaign is what they are rejecting. Theybelieve they go to the clinic and come back, but forthe campaign why do we then come to their houses?They get suspicious and think there is more to itthan we are telling them, which is why they rejectit. But for the routine they go to the hospital andclinic. They don’t have any query or complainabout it.” (Senior Health officer, Bauchi)

Engagement of traditional and religious institutionsThe engagement of traditional and religious institutionswas seen to facilitate the delivery of communication forchildhood vaccination in both states, and particularly inBauchi where resistant families and communities werecommonly found. All respondents indicated that suchengagement was a major boost to the immunizationprogramme since these institutions were trusted andrespected in many communities. This intervention was

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seen to improve the demand for vaccination and tocounter resistance in certain religious groups andcommunities.The cooperation and support of traditional and reli-

gious leaders as advocates for immunization played asignificant role in the vaccination programme, particu-larly in delivery of announcements in their churches ormosques and being part of community dialogue teamsto tackle the problem of vaccine hesitancy in certainhouseholds and communities.

Organisation of communication committeesAt the national level, some respondents noted that thepresence of a national Social Mobilization WorkingGroup that comprised of multiple developmental part-ners and highly skilled personnel was a major plus tothe delivery of vaccination communication. This groupdeveloped the strategic plan for communication andtrained health personnel at the state level. Similarly, inthe states and local government areas, the State andLocal Social Mobilization Committees were described asuseful in coordinating and engaging appropriate chan-nels for vaccination communication. In certain localgovernment areas, the presence of a functional WardDevelopment Committee (a committee that provideslinks between the community and the health system)was seen to contribute significantly in executing com-munication activities at the community level.

DiscussionCommunication has been described as a core compo-nent of service delivery in the immunization programmeand can play an important role in ensuring that childrenare fully vaccinated [22, 27–29]. However, our study sug-gests that vaccination communication was poorly under-stood by policy makers, with little mention of capacitybuilding in communication or communication in thewider context of social mobilization.Our study identified a number of other factors that were

reported as influencing the successful implementation ofvaccination communication strategies for both routineimmunization and mass campaigns. Weak political com-mitment impacted negatively on communication strat-egies for routine immunization services and contributedto difficulties with funding, deployment and training ofstaff, and provision of equipment and transportation espe-cially at lower levels of the health system. Indeed, fundingwas a major challenge in the implementation of mostcomponents of immunization delivery in both states. Thiswas confirmed in the Comprehensive EPI multi-year planwhere communication and advocacy received the leastbudgetary allocation compared to other components [30],and is consistent with the results from recent studies con-ducted in Cameroon and Nigeria [31, 32]. Poor funding

played a significant role in many of the barriers identifiedin this study.Several studies have suggested that regular exposure

through mass media and community channels is key topromoting vaccination [33–35], although the evidenceon the effects of such community-aimed interventionsto inform and educate about childhood vaccination isstill quite weak [36]. Furthermore, a lack of communica-tion activities outside campaigns may result in peoplenot recalling vaccination messages about routineimmunization. The implication of this is that if messagesare not given continuously people may forget or maynot attach importance to the issue.In many settings, health workers are seen as the most

important sources of information for parents decidingwhether their child should receive a vaccine [37, 38]. Alack of health workers, especially in rural and hard-to-reach communities, has important impacts on the effect-ive delivery of communication interventions. Addition-ally, the absence of skilled communication personnel,especially at lower levels of the health system, may limitthe capacity to counter negative information about vac-cines and achieve community support for vaccinationprogrammes [21], as observed in this study. The trainingof health workers needs to strongly address interper-sonal communication skills, so that health workers canmaximize on any opportunities for reinforcement onimmunization and child health more generally. Suchtraining can help to ensure that health workers providerelevant and comprehensible information in a respectfuland culturally sensitive manner [27].As also noted in other studies [20, 39], the engage-

ment and cooperation of traditional and religiousleaders was seen to facilitate the delivery of commu-nication interventions for childhood vaccination inNigeria, particularly in the context of campaigns, andto contribute to meeting the immunization pro-gramme’s objectives. The engagement of traditionaland religious institutions was more intensive inBauchi compared to Cross River, as rejection of theoral polio vaccine was seen as a major challenge inthe former. In Bauchi State, resistance was targetedmainly towards polio campaigns following rumoursand misconceptions that the vaccine included anti-fertility drugs or the HIV virus, as an indirect methodof checking population growth in the predominantlyMuslim states in the North. These rumours are simi-lar to those reported in other studies [18–21].Engaging religious and traditional leaders has also beendescribed as a useful and acceptable intervention in othercountries with large Muslim communities [40, 41]. Suchinterventions may be helpful in addressing communities’concerns about vaccination and the vaccination process,although their impacts need to be evaluated [42].

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In Table 2, we provide suggestions on areas wherehealth systems needed to be strengthened. Respondentssuggested that policy makers might consider improvingthe funding allocation for communication activities andintroducing regular vaccination messages outside cam-paigns. They also suggested that systems be establishedfor the management and timely disbursement of fundswithin vaccination communication programmes, espe-cially at the local level. This could ensure adequate plan-ning and timely implementation of communicationactivities for childhood immunization. Accountability

systems also need to be put in place and integrated intosystems that work to ensure that immunization fundsare released and used efficiently. We suggest that vaccin-ation programme managers and other decision makersneed to consider strategies to ensure that parents andcaregivers in rural and hard-to-reach communities haveaccess to information on childhood vaccination. Thiscould include providing information through routesother than health workers as well as strategies to im-prove the retention and quality of health workers inthese areas. Lastly, we suggest that the training of health

Table 2 Where health systems need to be strengthened in relation to communication for childhood vaccination

Health system issue Key findings from the analysis Implications for the strengthening of the healthsystem to support vaccination communication

Funding of vaccinationcommunication interventions

• Least budgetary allocation to communicationand social mobilization• Funds/incentives seldom available for routineimmunization and some costs borne byhealth workers• Overdependence on donors• Problems and delays with disbursement of fundsand materials at lower levels of the health system• Lack of funding for sustained communicationprogrammes for routine immunization• Communication strategies intermittent(minimal between campaigns)

• Consider improving the funding allocation tocommunication activities, which should becontinuous even after campaigns• Provide a regular source of funding forroutine immunization communication activitiesin the recurrent budget of States and LocalGovernment Areas as this may improve sustainability• Ensure that systems are available for themanagement and timely disbursement of fundswithin vaccination communication programmes,especially at the local level

Equipment and transportation • Lack of equipment (information, educationand communication (IEC) materials, megaphonesand vehicles) for adequate mobilization• Transportation difficulties

• State and local government SocialMobilization Committees and Health PromotionDepartments should be strengthenedto 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 ruralLocal Government Areas

• Consider redistribution of health workers,temporary staff from the pool of retirees orcommunity volunteers who can serve as mobilizers• Consider providing incentives for health workersin rural settings

Training • Lack of human resources for supervision offrontline health care providers• Training deficiencies, with large numbersof communication personnel notsufficiently skilled• ‘Cascade’ training model results in dilutionof training efforts

• Establish a system to monitor the appropriatenessand quality of training activities at the local level• Training needs assessments should be conductedfrom time to time• Supervision of Local Government Area mobilizersby state social mobilisers should be strengthened• Frontline communicators in the various LocalGovernment Areas should be provided withtraining guides or manuals which can be tailoredto 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 caregiverstowards vaccination

• Vaccine hesitancy and rejection in somereligious groups may impede receipt ofvaccination information

• Engagement of traditional and religious institutions andother community structures may be useful in counteringrefusal in some communities

Political support • Political support focused on campaigns only• Failure of State and Local Governments totake ownership of programmes• Health communication not seen as apriority by some policy makers• Lack of political commitment insome Local Government Areas

• Regular advocacy visits to political leaders• Improve accountability systems, particularly at the stateand local government level, to prevent misappropriationof funds meant for the communication needs of thevaccination programme

Community participation • Lack of community participation • Consider evidence–informed and locally appropriateinterventions to involve communities in planning andimplementation of communication intervention forboth routine immunization and campaigns

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workers be purposeful and enable health workers to tar-get communication to different groups in communities.Putting in place a system to monitor the appropriatenessand quality of training activities at the local level shouldbe considered while training needs assessments shouldbe conducted from time to time.

Strengths and limitations of the studyThe main strength of the study was the iterative and flex-ible nature of the qualitative research approach that weadopted when conducting the interviews. We had the op-portunity to go back to the respondents for clarification ofcertain issues and to ask questions which were not ad-equately addressed in earlier interviews. We also looked atthe national, state and local levels of health care deliveryin the country, allowing a more complete picture of vac-cination communication issues to be obtained.A potential limitation is that the study was conducted

during the pre-eradication era of polio in Nigeria, whenthe attention of governments and international agencieswas focused primarily on polio eradication. This mayhave skewed our findings towards issues relevant tocommunication in the context of campaigns. In addition,we did not interview senior staff in the National Direct-orate of Disease Control and Immunization responsiblefor routine immunization programme activities. How-ever, we included immunization officers at both stateand local levels of health care delivery and it is likelythat these respondents will have covered similar groundto those at the national level.

ConclusionOur earlier work has shown that a wide range of com-munication interventions are being used to promote up-take of childhood vaccination in Nigeria [32]. However,a number of health system factors such as funding con-straints, inadequate infrastructure and equipment, healthworker-related and political factors as well as commu-nity level factors, such as the attitudes of communitystakeholders and members, were found to hinder the de-livery of vaccination communication interventions. Im-portant differences were observed across and within thetwo states studied. Most of the barriers to implementingvaccination communication strategies found in thisstudy were more strongly expressed in Cross River State,and also in rural compared to urban areas. These differ-ences can be attributed to differences in infrastructure,resources (human and financial) and accountability as aconsequence of investments in the polio eradicationprogramme in Bauchi State.Programme managers and front line providers re-

ported that the most consistent barrier to delivering vac-cination communication was inadequate funding. This,they suggested, has greatly impacted on vaccination

communication delivery and the disbursement of com-munication materials, especially to areas where they aremost needed. In resource constrained settings like thosestudied, systems should be put in place to improve effi-ciency in how available resources are utilized. For in-stance, gains could be made by integrating routine EPImessaging into vaccination campaigns or packaging thiswith communication around other well-fundedchildhood interventions. Another important barrier wasthe absence of strong political will at Federal and Localgovernment levels for implementing communicationstrategies for routine immunization. This could be at-tributed to a poor understanding among political leadersof the importance of vaccination communication withinthe routine immunization programme.Decision makers need to look at how to address these

barriers so as to facilitate the implementation at scale ofevidence-informed strategies for communicating with par-ents and caregivers regarding childhood immunization.Addressing communication gaps, especially in routineimmunization services, will require bridging the currentfunding gap, addressing human resource deficits and en-suring strong political will for implementation. Facilitatorsfor implementation of vaccination communicationinterventions, such as the engagement of traditional andreligious institutions and the use of organised communi-cation committees, should be strengthened. If sufficientlyplanned, funded, and integrated with service delivery,vaccination communication activities could meet their de-sired objectives.

Additional files

Additional file 1: Guide for interviews with programme managers,social mobilization officers and development partners. (PDF 340 kb)

Additional file 2: SURE Framework of key domains for the identificationof factors affecting the implementation of policy options. (PDF 248 kb)

AbbreviationsCOMMVAC 2: ‘Communicate to Vaccinate’ Project 2; DPT3: Combineddiptheria, pertusis and tetanus vaccine, three doses; EPI: Expandedprogramme on immunization; FCT: Federal Capital Territory; GAVI: TheVaccine Alliance; LGA: Local Government Area; LMIC: Low and middleincome countries; NPHCDA: National Primary Health Care DevelopmentAgency; WHO: World Health Organization

AcknowledgementsWe would like to acknowledge the participation and enthusiasm given tothe study by the Commissioners of Health and their team in both CrossRiver and Bauchi States. I would also like to thank my team of researchersfrom Bauchi and Cross River States: Dr. Festus Nkpoyen, Vera Udelikwu, AbasiAkpakpan, Inyang Asibong and Hajia Rahinatu Aliyu for assisting with thedata collection and logistics.

FundingThe Research Council of Norway (Project 220873) funds the Communicate toVaccinate 2 project. SL receives additional funding from the South AfricanMedical Research Council.

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Availability of data and materialsPlease contact the corresponding author with any queries regarding theavailability of the data supporting the findings of this study.

Authors’ contributionsAO, AOI, CG and SL developed the research protocol. AO and AOI collectedthe data. AO wrote the first draft of the article with input from AOI, CG, SLand AF. All of the authors read and contributed to the manuscript and agreewith the material presented. ICMJE criteria for authorship read and met: AO,AOI, CG, AF, GE, HA, AM, JK, SH, JC, YC, XBC, GR, SL. All authors read andapproved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consent to participateWe sought and obtained ethical approval from the Cross River State HealthResearch and Ethics Committee and the Bauchi State Health Research and EthicsCommittee. The Regional Committee for Medical Research Ethics in Norwayassessed the project as not requiring ethical approval under the Norwegian Act onMedical and Health Research. We obtained written consent from each respondentfollowing explanation of the study’s aims and objectives. Permission was alsosought and obtained from participants before audio-recording each session.

Author details1Community Medicine Department, University of Calabar, P.M.B 1115, CalabarMunicipality, Cross River State, Nigeria. 2Norwegian Institute of Public Health,Postboks 4404 Nydalen, 0403 Oslo, Norway. 3Institute of Health and Society,University of Oslo, P.O box 1130, Blindern 0318, Oslo, Norway. 4SociologyDepartment, University of Calabar, P.M.B 1115, Calabar Municipality, CrossRiver State, Nigeria. 5Departamento de Saúde, Direcção Provincial de Saúdede Nampula, Av. SamoraMachel n° 1016 R/C, C.P. N° 14, Nampula,Mozambique. 6Centre for Health Communication and Participation, School ofPsychology and Public Health, La Trobe University, Health Sciences 2, Victoria3086, Australia. 7Faculdade de Medicina, Universidade Eduardo Mondlane,Maputo, Mozambique. 8International Union for Health Promotion andEducation, 42 Blvd. de la Libération, 95203 St. Denis, Cedex, France. 9SwissTropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.10University of Basel, Petersplatz 1, 4003 Basel, Switzerland. 11Evidence-basedHealthcare Program, Pontificia Universidad Católica de Chile, Avda. LibertadorBernardo O’Higgins 340, Santiago, Chile. 12Health Systems Research Unit,South African Medical Research Council, Francie van Zijl Drive, Parowvallei, POBox 19070, 7505 Tygerberg, South Africa.

Received: 13 August 2016 Accepted: 11 January 2017

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