Socio-Demographics Characteristics of Participants
A total of 72 health workers including vaccinators, validators, EMID recorders, social mobilizers, and paper recorders participated in the study. About 3 out of every 5 (58.3%) participants were female by gender, as over one-quarter (27.8%) of the study participants are National Certificate Examination (NCE) degree holders. The mean age of the study participants is 34.3. About 2 out of every 5 (40.3%) of the study participants fall within the 29–38 age bracket. (Please see Table 1)
Table 1
Socio-demographic Characteristics of Participants
| Niger State | Benue States |
Characteristics | Frequency | Percent | Frequency | Percent |
Gender | | | | |
Male | 15 | 41.7 | 15 | 41.7 |
Female | 21 | 58.3 | 21 | 58.3 |
Age Group | | | | |
19–28 | 12 | 33.3 | 10 | 27.8 |
29–38 | 11 | 30.6 | 18 | 50 |
39–48 | 9 | 25 | 5 | 13.9 |
49–58 | 4 | 11.1 | 3 | 8.3 |
Educational Attainment | | | | |
Secondary | 8 | 22.3 | 6 | 16.7 |
Post – secondary | 24 | 66.7 | 27 | 75 |
University | 0 | | 3 | 8.3 |
| 36 | 100 | 36 | 100 |
Demand Generation Strategies Deployed by the Mobile Team
Community Entry and Visit to the Community Leader
Generally, evidence-based practices have revealed that vaccinations and/or immunizations are usually driven either through fixed teams or outreach teams. However, outreach teams are significantly integral to the optimization of immunization/vaccination services, especially in communities with limited access to healthcare services. Recognizing the value of mobile teams, our study inquired from the teams how they carry out their activities and ensure seamless operations within the communities. The Mobile Team interviewed expressed that to successfully carry out their activities as a team, they strategically executed their plans starting from visiting the community leaders. Community leaders are informed of the reasons they are in the community and are then leveraged to get community members informed and vaccinated for COVID-19.
Like, in my team, I'm the supervisor. Let me say it like that. When we go out to the community, we just go straight to the chief of the community here. We let the chief know that this is what we are coming here for. We tell them about how we are going to take the vaccination to them, and how is the effect and what they are going to do for the vaccination. The chief will allow us or will send any of the villagers to just tell others that this is what these people are here for. They are not here for harm. They will allow our town announcer to announce for them so that we take the vaccination to them. ( FGD/Mobile Team/Katsina-Ala LGA/Benue State)
When we go to the community as my other person said, we will make sure that we go to Mai Angwa, and when there is palace there, we go to the palace too to tell the king who we are and what we want to do there. We tell them we are from the health center in the ward, and that we want to vaccinate people for COVID-19 in the state. They will now tell us to come back the following day and before we come, they will tell their people for us. They even use to tell us to come early so that we can meet people at home that many people will go to farm ( FGD/Mobile Team/Wushishi LGA/Niger State)
Awareness Creation at the Community by Social Mobilizer
The second layer of demand generation activities deployed by the mobile team is to engage a social mobilizer who goes from street to street, household to household to sensitize the community dwellers, especially in their local dialects about the need to avail themselves for the vaccination exercise. The social mobilizer provides details on the visit of the mobile team for the vaccination exercise, the venue, days, times, and duration.
So, first of all, if we want to go to the community for vaccination, first we arrange for the week, within the weekend we arrange the community we’re supposed to go day by day. So, if we have to go to this same community, we inform our Mobilizer to go to the community and mobilize them before the day we are supposed to go. OK, the information that was given to them, we have come for COVID-19 vaccination. Give them some information that is going around about the vaccination…... We try our best to convince them, to tell them that the vaccine is effective, safe and there’s nothing about the vaccine. So we try and convince them with the help of God, some of them will accept and take the vaccine. That’s what I have to say. ( FGD / Mobile team BOSSO LGA/Niger State)
Whenever we are going into a community, first we send our mobilizer to go ahead of us so that he go and clear the ground for us and then we go after him, then we sensitize the people by educating them, giving education concerning COVID and other related diseases, then we vaccinate them. Not only that, we sometimes cooperate with the KNCV team now that they are on ground we collect some of the material like BP apparatus and then HPSL machines and then we test the proof of blood sugar and then high BP (( FGD/ Mobile team Makurdi LGA/Benue State)
The teams engage in highly coordinated activities by structurally planning their locations in a community on the first day of the week, before subsequently entering the community. Additionally, the teams drive their vaccination activities through the key stakeholders at the grassroots level and sensitize not only the stakeholders, but also the community members on the value, and potential benefits accepting the vaccine offers to community members. The sensitization of community residents is equally an approach to addressing misconceptions and conspiracy theories that may be pervading the communities the teams found themselves.
Perceived Contributions of the Mobile Team to COVID-19 Vaccination Optimization
The adapted WHO Health System Building Blocks Framework guided the grouping of the emerging themes from the study findings under the relevant building blocks. The following findings presented in this section provided insights into the perceived contributions of the mobile team toward the optimization of COVID-19 vaccination in the two selected states:
I. Service Delivery
All the participants who participated in the discussion believed that through the work they do in several communities in their local government, they have been able to improve vaccination coverage in their states, whilst they are trying to support their people through the administration of COVID-19 vaccine as a prophylaxis for community members. The following are some of the thematic areas the mobile team provided service at the community level:
Clarification of Misconceptions and Beliefs
Before the visit of the team, many of the community dwellers held several misconceptions about the COVID-19 pandemic and the vaccination which had led to the hesitancy experienced in the uptake of the vaccine. Hence, part of the most essential services of the/ Community Outreach team was to unravel and clarify those misconceptions.
… Secondly, concerning issues that some of them were scared of, we gave clarification and explanation. A lot of them decided to be vaccinated having gotten the explanation and all that ( FGD/Mobile Team/ Wushishi LGA/Niger State)
Yes, what we did as a team was that we encouraged others to participate in the uptake of COVID-19, for example, if we go to any community, maybe some people have the intention of not taking it because of one thing or another or the wrong perception about it. We would like to tell them that the vaccine is safe, that we as a team and the health workers that visited them have taken the vaccine before and nothing else has happened to us. So, it's a way of encouraging them that the vaccine is safe for everybody to take. ( FGD/Mobile Team / Ogbadibo LGA/Benue State)
My team’s contribution to the community or to the Otukpo Local government as a whole, vaccinating people, we are preventing them from having the illness that they are vaccinated against, 2) we are telling them the importance of what we are doing or what the government is helping them to do, because in other areas, we have heard about people that COVID-19 have killed, but by the special grace of God because of this program that is here, it help us that such a way that we don’t experience something like that, and based on the information that was given from the radio and our mobilizers going to talk to them, it gives them a kind of motivation, because at the first time people were scared of the vaccine that it’s not good, that it is this and it is that, but based on the information and the corporation form the team again, to the community, people have started coming out unlike before, so now I think this our services have helped the community with a lot of ( FGD/Mobile Team/Otukpo LGA/Benue State)
Improved Service Accessibility
The services provided by the mobile team at the community level are effective drivers of increased accessibility to the uptake of COVID-19 vaccines, as communal residents are usually reluctant to visit health facilities for vaccination due to one reason or another. Community dwellers who reside in communities that are far from the fixed vaccination centers usually face the challenge of transportation, but the consistent activities of the mobile/community outreach team have helped bring the COVID-19 vaccination services closer to these groups.
In addition to what he has said, the proximity of the vaccine; You know ordinarily Most of them find it difficult to transport themselves to the health facility but our frequent going to their communities makes the vaccines closer to them, available to them without them spending transport to come. ( FGD/Mobile Team/ Wushishi LGA/Niger State)
The work we are doing has helped a lot to access vaccines, because especially in this era where everything is stressful, eating is a problem, some people want to be vaccinated, like the place we visited today, a bike from this place and none of us is even leaving around here, but a bike from this place, just to go is 300 naira coming back they would not even carry you for that 300 naira, and some people want to have access to the vaccine, but due to the economy we are facing now, they would not come, me I have looked at this work that has helped a very. It has gone a very long way in making people access the services even right on their doorsteps. So, this work has helped us a lot ( FGD/ Mobile Team/Otukpo LGA/Benue State)
Improved Coverage
As a result of bringing COVID-19 vaccination service closer to the community dwellers the number of persons who took the vaccine increased in each of the respective LGAs. Hence, the barriers of misconceptions, vaccine safety, and distance to name a few were handled by the mobile team.
It helped because as part of the staff in the clinic, the work we did with people in the villages also increased the number for COVID-19 immunizations. We normally convince them that the vaccine is supposed to help them not to have COVID-19. You know some people do not believe that the disease is in Nigeria, and they will say that it is a lie, but because of our work in the villages, we save the stress of our people in the clinic. And we make sure that the village people are protected (FGD/Mobile Team/ BOSSO LGA/Niger State)
Our work has affected vaccination coverage in the sense that, a lot of people might not have the time to go to the fixed post for vaccination but since we have been going out, we have been getting them there in their various settlements. At least some of them will say that they cannot come to the facility. There are a lot of things they have been saying about COVID-19 and even the vaccine, but when we move close to them, we explain to them the benefits of this, So many of them if we explain to them, they would then decide to take the vaccine ( FGD/Mobile Team/Makurdi LGA/Benue State )
II. Health Workforce
All participants involved in the discussion agreed that their engagement as mobile teams to strengthen the health workforce to optimize COVID-19 vaccination tremendously improved the capacity of health workers, to increase the coverage of COVID-19 vaccination in various communities, especially the hard-to-reach communities in their respective local government areas. Participants also stressed that they were usually committed to the work irrespective of the few deterrents the work presented to them. This was evident in the expression of teams who emphasized that:
For me, I say to them that they should not be worried. We are doing it for a community purpose. We are helping ourselves. Our father, our mothers, our brothers. We don't have to earn something, anything. Sometimes you do work, it's only God who will reward you. Let's just help ourselves and help the community. We don’t give our ( FGD/Mobile Team/Katsina-Ala LGA Benue State)
I think the work we did in the community really helped our people in the facility, and it even made the number of COVID-19 go up very well. Like now, we always go and convince people, and even go and block them when they are going to farms. We also used to give people vaccines immediately after morning prayer in the mosque. ( FGD/Mobile Team/Edatti LGA/ Niger State )
Health Information System
A Structured Paper and Electronic-based Form of Data Reporting
Participants expressed that they adopt a bottom-to-top-level reporting structure, as they relay their collected data to the ward focal person, who in turn forwards the reported data to the monitoring and evaluation officer at the local government level, and this goes to the state-level officer, who is likely to report the data in the National Call-in Data platform for COVID-19 vaccination. Participants equally expressed that team leads re-evaluate the submission of data through the appropriate channels to ensure sustainability from the team, as the implication for reporting is to attest to the increased coverage of the vaccinated populace in the various local government areas across the two states.
One thing is that once we get the detail of the client, and then we, on our EMID app, think once we do it, automatically the thing would just synchronize and the thing would just go like that, then the whole thing now is shifted to the validator, afterward then I think it’s a done deal already. We do ask them their names, ages, numbers date of birth, then date of vaccination time. Then we send a report first from the unit, which you send to the ward focal person, from the ward focal person to the M&E, from the M&E to the local government officer, and then to the state, just like that once we finish any session. Like today's job, we make sure that everybody that is acquainted with their position, we make sure that they send it like the person that is responsible in our team, to send it, the thing keep going gradually, from our team now, from the unit to the ward focal person and the focal person would do also his work and gradually till it gets to the climax of the whole thing (FGD/Mobile Team/Otukpo LGA/Benue State)
Let’s assume now, this man is already immunized, and he came to me as an EMID. I will ask him what his name is. Since he is a male, and no need to ask for his sex, I will put in M and ask him for his date of birth, I will ask him ward and the community. So, I later go to the vaccine section if it is Moderna or Pfizer, so I will now register him, ask him to give you his phone number, and later do it. At the end of all our vaccinations, I will now synchronize my data and send the report to the focal person and the M&E in the LGA, and the M&E in the LGA now send it to the state. I think the state now sends it to the national level. I will also send my report through the ODK to Sydani. And if there is no data, I used to tell my team people and they will contribute money for me to buy data so that I can send the vaccine report (FGD/Mobile Team/Edatti LGA/Niger State)
Challenges Encountered during Vaccination Exercise
The study equally adapted the Health Systems Framework to document the challenges of the health workers conducting outreaches in various communities across different LGAs in Benue and Niger states.
Service Delivery
Difficulty in Breaking the Barrier of Misconception and Vaccine Safety
Despite the efforts made by the team to clarify the misconceptions, and beliefs around COVID-19 and as well as vaccine safety, some of the community dwellers in certain instances still proved difficult as they stuck to what they previously knew. Hence, reaching such a community might require a special form of understudying. Below is feedback from our study participants:
Whenever there is a misconception on the side of COVID-19, when we come there, we see that there are a lot of stories about the vaccine, and even when we correct them, some of them are still spreading the stories. So, we find it very difficult to convince people, there are some places we go and break barriers, but there are places we cannot go once and break barriers ( FGD/Mobile Team/Makurdi LGA/Benue State)
Demand for Incentives by the Locals
Another challenge encountered by the mobile/community outreach team was the demand for incentives in the form of money, and other consumable items from the locals. Some of the community dwellers were not willing to avail themselves for the vaccination if there were no material rewards or incentives attached to it. Findings from the Focus Group Discussion are presented below:
We have had many challenges when we go for the field, in many settlements to discuss, sometimes when they come around, they will say, “Is it because of the town announcement that was made, you are here?” Why are you not bringing money or even if it is Maggi, why are you not bringing anything for us to share for the people? (FGD/Mobile Team/Edatti LGA/Niger State)
We used to get challenges because before they come if you tell them that they should come and take the vaccine, they will say, is this money that we are going to give them? This vaccine is not going to give them anything. Is it food? If there is no food, we should go, we cannot give them the vaccine. Then we visited the place again. Then, the social mobilizer will help us to explain to them so that they will understand and come and take the vaccine (FGD/Mobile Team/Chachanga LGA/Niger State)
Difficulty with Accessibility and Transportation
Participants also mentioned the challenges they experienced with reaching people, especially those in hard-to-reach communities. There are situations where the roads are not motorable, limited means of transportation, and hikes in transportation fares during rainy seasons to such areas. They emphasized these outlined issues as significant hindrances to vaccination coverage.
First of all, the challenge that we’ve had at times is farther communities that are not close to the health facility, therefore you must look for a way to go ahead of the vaccination team to tell the people. Sometimes, if logistics is not provided, we would have challenges in terms of getting to these places and it is a very far place. Sometimes we spend our money on going to that place and it is not good for us, because our transport allowance will not cover it (FGD/Mobile Team/Wushishi LGA/Niger State)
Another challenge we encounter is mobility, one thing we do is enter villages, where these people, the poor masses that cannot afford to take these vaccines, or where transport issues might be a problem to come to the primary health care to access these vaccines (FGD/Mobile Team/Otukpo LGA/Benue State)
Although the distance to communities and mobility issues, particularly during the rainy seasons were a major impediment for health workers (mobile teams) to access communities for the optimization of COVID-19 vaccination, however, the teams are usually committed to ensuring that they get to the communities by any means available to them.
Health Information System
Inadequate Stationaries and Reporting Materials
According to the participants, two major issues acted as a menace to the documentation and reporting of vaccination data from the field activities among mobile teams during their COVID-19 vaccination exercise. These were paper-based documentation and technological-related challenges. Participants revealed that the documentation of the vaccination exercise is usually affected by a lack of registers and a shortage of writing tools. These eventually result in inconvenience for the team, as they temporarily substitute the absence of registers with an exercise book which would require them to re-document the information on the registers when they become available. Additionally, the health workers expressed that they experienced significant challenges that are directly and indirectly related to technology or in this case, electronic documentation. The following excerpts from the study interview provide more evidence for this section:
My major challenge is my writing tool, which is my pen because I am doing more writing as a paper recorder and I always have to document everything on paper and card, but sometimes my pen will stop working and sometimes the ink will finish, and there will be no place to buy another pen nearby. Also, when they have not sent the cards that we will give to the people we vaccinate, it affects us and is another challenge that we face. (FGD/Mobile Team_/Ogbadibo LGA/Benue State)
Sometimes we do not have cards that can help us scan the QR code, and it used to affect us in the field. Now that there are no registers, we use exercise books to register people that are coming. One, getting all the information in the register transferred to the notebook is not easy and the notebook is sometimes too small for the two spread pages to contain it all. It is a challenge there and you know exercise book can tear quicker than the register and it can easily get lost (FGD/Mobile Team/Ushongo LGA/Benue State)
Limited Internet Access
Participants emphasized that they experienced several challenges that were related to entering and submitting their data electronically. Essentially, the limited power supply in their communities had a significant negative influence on electronic gadgets used for collecting clients' information and reporting daily coverage data. Additionally, participants also experienced network issues in certain distant communities during some of the outreach visits. Similarly, there were d concerns over the issues associated with accessing and operating the electronic app adopted to report COVID-19 vaccination data at the national and sub-national levels. Evidence from the discussion sessions with the mobile teams is presented below:
The challenge I have sometimes is with my data. If I enter where I want to synchronize sometimes, I just see off I can’t see any clearance line, to tell me or show that it’s sent or done, I can’t see it. So sometimes when am confused I later tell my oga (boss) they use to call the LIO, and he will give us advice on what to do if we go to a place that doesn’t have a network (FGD/Mobile Team/Edatti LGA/Niger state)
For more than four months we don’t have light. When we go for outreaches, we go with our phone and the charger, when we charge them because sometimes as you see us like this we are going to the full settlement for a whole day. So, when we finish like this, I am a validator because NG is the identification number for the people we want to vaccinate. So, I will type out all the NGs that are on my Kobo and collect them one by one. So, after typing this one back into my phone, I will send it before the battery I have left on my phone is finished /Mobile Team/Wushishi LGA/Niger State)
We met our LIO one time telling them we don't have data money because this work consumes data a lot and at times the money … in fact, there was a time they sent 2300 naira to our account each When we consider our transportation, our feeding money and how can we cope to even buy the data. So, they should if they can support and be sending the data directly to us. To subscribe for us directly, so, that it would save the work (FGD/Mobile Team/Bosso LGA/Niger State)
Sending this vaccination information needs resources, which is an internet data subscription. So, you must have your internet data subscription. If you don't have your internet data, your reports are not going to be delivered. So, we use an internet data subscription for sending this report (FGD/Moile Team/Katsina Ala LGA/Benue State)
In addition to that one other major challenge is the fluctuation in network, sometimes you go to a community you have a cluster of people after explaining to them the need to be vaccinated and it’s well accepted, trying to get their counts captured immediately sometimes network fluctuates and it becomes a problem after a while some times we can go ahead and capture these guys and then give to them the vaccine (FGD/Mobile Team/Otukpo LGA/Benue State)
Mobile Team Experiences on COVID–19 Vaccine Integration on Extant Health Structures
Interestingly, all the study participants emphasized that they integrated COVID-19 vaccination into at least one extant public health intervention in their respective localities. While some participants leverage the routine immunization services offered through outreach to communities, others utilize other public health services like HIV/TB testing services.
Participants exuded that integration may also be a challenge for the teams when they experience certain hindrances. Teams partnering with other implementing partners expressed that the occasional; unavailability of their partnering team affects their performance, as they seem to have established a symbiotic relationship with them, and as such performance tends to be limited when the other team is unavailable. Additionally, teams who leveraged routine immunization are sometimes troubled by the absence of COVID-19 vaccines, while the RI antigens are available.
To get to more people what we did was that we were doing RI and COVID-19. So, we combined all vaccinations every day for the RI and the COVID-19 vaccine. So by the time we start, we call the town announcer to explain to them, Even the child, we tell the caregiver to bring the child, those aged zero to 59 months, 0–11 months, so everybody came, so like our vaccinator, we arrange the vaccine for each of the category of people we want to vaccinate ( not audible) if they have the card for the RI they can bring it and we give the child the RI vaccine. We also ask the caregiver if she has received the COVID-19 vaccine. For those who said “no”, we would administer the vaccination to them (FGD /Mobile Team/Edatti LGA/Niger State)
Okay, so in our team, we work with teams from other partners, and we used to integrate. We go to the HIV clinic with the Breakthrough team and do awareness campaigns with them too, and we also work with KNCV. This influences because like, KNCV, the BP apparatus that we are using, most people will not intend to take the vaccine, but once they see that they will check their BP, it will motivate them to come for it and at times, if they check their BP, we will tell them that as you have check your BP it's good that you take the COVID − 19 vaccine also (FGD/Mobile Team/Makurdi LGA/Benue State
The study participants took the initiative, either on their own, or through the stakeholders at the LGA and state levels, and/or partners working with the state health authorities, to ensure the optimization of COVID-19 vaccination. This strategy equally adopted integrated campaigns of public health interventions to leverage and drive vaccination exercises in the communities. The adopted strategy is therefore highly plausible for similar interventions that may occur in posterity. Furthermore, participants expressed that the little challenge that comes with integration may be impactful.
The only challenge is that when one is not there, to some extent it might affect the work. Just like for instance, the breakthrough is not there. Maybe we are going to a particular community and then Breakthrough has not come to play the role they are to play to some extent. The uptake of vaccination will not be as it should have been. So, when they come, just like we said when they play music and all that attracts, it draws people's attention. So, the moment they're not there, it will then turn up will be encouraging not as it should have been, because at that level it's only the mobilizer that is doing it, and he has to go from one door to another so it, to some extent, it's not that easy (FGD/Mobile Team/Makurdi LGA//Benue State)
The challenge is that when we want to go to the community to go and vaccinate the community, we go and collect vaccines. they can have Penta and BCG, but they will not have COVID-19 and we cannot go to the community alone with RI vaccines. (FGD/Mobile Team/Bosso LGA/Niger State)