Feasibility of using CHWs to generate reliable population data
Table 1 compares the data collected by the CHWs and the district population as projected by UBOS(22). Overall, 2,048 children were registered by the CHWs through house-to-house registration as compared to 1,889 according to UBOS estimates. This represents a +7.8% difference. In the intervention facilities, there was a difference of 7.9% between the number of children registered by CHWs and estimated UBOS projections. In the control facilities, there was a difference of 7.5% between the number of children registered by CHWs and estimated UBOS projections.
Based on the analysis of the qualitative data, we assessed and analyzed the experiences, practicability, challenges and suggestions for improvement for house-to-house registration of eligible infants for immunization.
Overall, the health workers reported that the house-to-house registration was a practical and doable exercise which was also accepted by the community. All the in-charges of health facilities who were involved in the study appreciated the engagement of CHWs to collect immunization data at household level and acknowledged this was a feasible intervention as illustrated below;
The Health Workers (HWs) affirmed that it was one of the reliable ways of knowing the accurate target population. They further attested that it was a good experience of knowing the true location of eligible children for further follow up.
The challenges cited by the HWs were that some parents thought the registration of children were for political ambitions and/or financial gains. Indeed, some households were expecting a financial reimbursement for the registration. The registration was conducted during the planting season where a number of families had migrated to the forest reserves for agriculture. Other households thought that their children were going to be recruited into religious cult groups. The known vaccine resistant households refused registration.
The HWs recommended that the house-to-house registration needed to be conducted on a regular basis, at least twice a year. They emphasized the need to plan and facilitate CHWs with logistics to be able to carry out the exercise. They suggested that the community needed to be sensitized on the importance of the house-to-house registration
The CHWs reported that the house-to-house registration was a feasible exercise and highly acceptable by the community.
“We discovered children who had only received one antigen like BCG and others had only received up to DPT3. Also, a number of mothers after receiving DPT3, they are told to come back at the health facility when the child is 9 months, but they never turned up. However, house to house registration helped a lot to identify children who had missed some doses like measles. For example, a child was 2 years old but looking at the health card, he had received vaccines up to DPT 3”, (IDI with CHW)
“Some children were visitors from another sub-county. Some households were locked and the neighbors told us that they had gone to the forest reserve to plant maize and would return after harvesting,’’ (IDI with CHW)
“Through the registration, I discovered that some children had even died without us knowing at the health facility’’, (KII with health facility in-charge).
The CHWs attested that it was an important exercise because it provided an opportunity to identify children who had; missed and or defaulted on their immunization schedules; died; relocated; visitors; migrants; and critically ill. House to house registration presented the opportunity for the CHWs to know their target population for their respective villages including specific location of households for these infants. CHWs were able to know the vaccine hesitant households. They were able to know the visitors and migrants and also locate families that had migrated to other locations. They were able to sensitize the mothers on the importance of immunization and remind some mothers/caregivers on the subsequent vaccination appointments for their children.
The challenges reported by the CHWs were that some villages were big and they had to walk long distances; the vaccine resistant households refused to give information on their children and some would hide the children; it was a rainy season and yet they lacked protective gear such as raincoats, gumboots and umbrellas; public misconception that names of their children were written for financial/political gains; some few households were hostile towards the CHWs; some households demanded for monetary payments for the registration exercise.
The CHWs recommended that they should be provided with protective gear such as umbrella, gumboots, and rain coats to be used during harsh weather. They requested for bicycles to ease their movements and t-shirt for easy identification by the community members. They requested for sufficient logistics to ease their activities while in the field.
Feasibility of using CHWs to track and link eligible children to points of service
Based on the analysis of the qualitative data, we assessed and analyzed the experiences, data harmonization, practicability and suggestions for improvement for monthly EPI data audit meetings and home visits in order to determine CHWs ability to track and link eligible children to points of service
Monthly EPI data audit meetings
Overall, there were a total of 9 data audit meetings held from July to September 2020 in the three intervention health facilities. Each facility held 3 monthly audit meetings where children defaulting were identified, listed and given to the CHWs for follow up via home visits in the community. Overall, 531 children were listed as defaulters and later followed up by the CHWs via home visits. Of these 362 (68%) returned for immunization.
“I found the monthly meetings very useful. The defaulter tracking register was very important for tracking. Every month, after the meetings I updated the book and noted the children who had returned for immunization after being followed by the community health workers through home visits’’, (KII with in-charge health facility).
“These meetings are important. We need to include these monthly meetings in our annual work-plan so that they can be funded’’, (KII with in-charge health facility).
The health workers reported that monthly data audit meetings were important and useful as the monthly EPI performance was shared. They reported that the process for the meetings were that the in charges would identify defaulters from the child register, list them in the defaulter’s register and also provide lists to the CHWs for subsequent tracking and linking to the health facility. During the meetings, the defaulter’s register would be updated and children returning for immunization identified.
The health workers reported that regular funding was needed to sustain these meetings.
Overall, CHWs reported that the monthly EPI data meetings were beneficial and feasible. They reported that the data audit meetings were very helpful in identifying children who were defaulting and ensuring each CHW obtained the particulars of these children for further follow up. The meetings were useful in updating the health workers on the progress of the work of the CHWs in regards to tracking defaulters via home visits. In these meetings defaulting children who had returned for immunization were also identified and defaulter tracking register was updated. CHWs also reported that they learnt how to approach the community to do home visits and how to conduct health education on immunization during home visits. CHWs reported that they got more involved with immunization activities and realized their role as bridge between the community and the health facility. In addition, they reported that the project tools used for audit meetings and defaulter tracking were helpful.
Home visits-defaulter tracking
After attending the monthly EPI data audit meetings, the CHWs were given a list of children defaulting in their respective villages and tasked to conduct home visits and subsequent linkage to points of service.
“Monthly data audit meeting helped to identify the children defaulting for my village catchment area and the list given to me by the in-charge is what I would use to track these children”, (IDI with CHW).
“From these meetings I learnt a lot of things like how to communicate to the mothers/caregivers; how to deal with hostile families. I learnt a lot about immunization and the schedules and I was able to teach the mothers during the home visits”, (IDI with CHW).
Overall, the CHWs reported that the home visits were feasible and a doable exercise. They reported that good number of mothers were not aware of benefits of immunization. There were some hostile households and vaccine hesitant communities where local leaders and police had to be involved.
Some of the reported challenges faced by the CHWs were that the exercise was conducted during a rainy season and yet they did not have protective gear such as raincoats. Other challenge was hostile families that were suspicious and harsh towards the CHWs. They also complained of long distances they needed to travel to get some distant homes. In addition, they found that some families had migrated to other locations for farming. They reported that some known vaccine hesitant households would intentionally hide their children away and lie about their vaccination status.
“Through the home visits, I was able to move long distances into hard-to-reach areas such as forest reserves, islands. In one household I visited, the child was disabled and had missed most of the vaccine antigens. The mother was also lame and HIV positive. She complained that she had difficulties accessing health care due to her disabilities,’’ (IDI with CHW)
“We have a problem of the religious cults like triple 666, njiri-kalu and tabliqs that do not allow immunization. These cults tell their followers that immunization is bad and against their beliefs. You find that all children from these households are not immunized and even when you go to sensitize them, they hide away, (IDI with CHW).
“This COVID has also brought a lot of problems. During the lock down, mothers were fearing to go to the health centers resulting in high numbers of children defaulting,’’ (IDI with CHW)
“One of the major reasons for defaulting is migration. When the planting season starts, a number of families due to lack of land migrate to the forest reserves to be able to farm. They go for like four months and yet there are no health facilities in the forest reserves. These children will therefore default,’’ (IDI with CHW).
The CHWs reported a number of reasons for children missing/defaulting from their immunization schedules. They reported that Some mothers complained about stock out of vaccines discouraging them from returning their children for immunization. Mothers complained that children get a lot of injections and some of them cause swelling of the body parts and hence are hesitant to take them for immunization. Some mothers complained about being victims of domestic violence making them unable to take children for immunization. A number of families migrate for various reasons such as farming for example in forest reserve areas where they’re unable to access health services including immunization services. Some caregivers reported forgetting health cards at their homes when they visit new areas. Some mothers are busy in agricultural activities that they forget about immunization. A number of community members are ignorant about the value of immunization. Lock down due to COVID-19 with restricted movements resulted in defaulting. Some households believe in some religions that forbid immunizations.
The CHWs reported that home visits advanced equity as they were able to reach the hard-to-reach households including vulnerable population:
Effectiveness of the interventions in increasing immunization coverage
The effectiveness of the interventions in increasing immunization coverage was measured by comparing the coverage of the various antigens between the intervention and the control arm. The coverage at the end line for all antigens was significantly higher in the intervention arm as compared to the control arm (Table 2).
A comparison in the intervention arm before and after the intervention also showed significant increase in the immunization coverage for most of the antigens (Table 3).
The effectiveness of the interventions in increasing immunization coverage was measured by comparing the coverage of the various antigens in the control arm before and after intervention.
A comparison in the control arm before and after the intervention also showed significant increase in the immunization coverage (Table 4).