This project was designed to assess the effect of a culturally adapted audio-visual workshop intervention to empower traditional birth attendants towards promoting the uptake of maternal and neonatal immunizations.
A number of studies [17, 18, 19] have shown that most TBAs are middle aged or older married women, with experience in child birth and they are highly respected in the rural communities they practice in. This was similarly observed in the present study where the TBAs were all women and the average age was 47 years with an average duration of 16 years practice as a TBA, performing an average of ten birth deliveries per month within their communities.
It was also observed that 72% of the TBAs were married. In the context of culture, especially within the rural communities among the women folk, married women are respected and furthermore, as TBAs, they have a long and consistent history of assisting birth deliveries in a friendly and caring manner that are readily available and affordable. This has endeared them to the community where they practice with wide spread social and cultural acceptance. This acceptance and intimate relationship they have established over the years make them uniquely positioned to act as effective agents to dispel the erroneous cultural and traditional beliefs and misconceptions about immunization which appear to be more evident in rural communities.
In spite of their unique position in the communities, the level of education of the TBAs is a challenge as studies have reported TBAs having no formal education or having some primary or some secondary education [17, 19]. In the present study, the majority of the TBAs had either a primary or a secondary education as the highest level attained but it was also observed that up to one quarter of the TBAs had a tertiary education. Similarly, a study in Nigeria  also reported having TBAs with a tertiary level of education. This observation may not be unconnected with the high unemployment rate in Nigeria for graduates of tertiary institutions; and probably, this has forced some of them to relocate to their communities and engage in traditional birthing activities as a means of livelihood. Notwithstanding the proportion of TBAs with a tertiary education, the majority still have either no or incomplete education experience, compounded by differing traditional and cultural beliefs. This poses a challenge in the development of effective communication materials that would impact significant knowledge on a maximum proportion of recipients with differing customs and traditions.
Nevertheless, the present study took into cognizance the level of literacy, language barriers, customs and traditions in the development of the audio-visual communication content but however, in the study’s post intervention period it was observed that there was a statistically significant association between the level of knowledge of the TBAs and the zones they reside and practice; as this, may have been influenced by the differing traditional and cultural beliefs. This further highlights the challenges of developing a uniform communication content for a mix of clusters characterized by low literacy and varying cultural and traditional beliefs.
Despite these challenges of the audio-visual workshop intervention, its effect on knowledge was statistically significant across the zones and in the total population of TBAs. This further emphasizes that, effective training of TBAs with appropriate materials can improve knowledge as similarly reported in other studies with training interventions, where knowledge had resulted in improved maternal and neonatal outcomes [12,16,17,20].
The knowledge acquired by the TBAs may empower them to be at least willing to effect change as was observed in the present study where all the TBAs post intervention were now willing to encourage the uptake of immunization among their clients.
The study had limitations such as the content of the workshop communication messages. This was developed specifically for the traditional birth attendants by taking into cognizance their varying literacy levels and different cultural and traditional beliefs. However, communicating a unifying message with an appropriate mix of information and clear understanding for this diverse group of participants was still challenging. The resultant less than perfect uniform messaging could have impacted on the degree of knowledge acquisition, positive attitude development and invariably, their willingness to promote immunization. Another limitation was the translation of the questionnaire from English to the native language of Igbo by the interviewers when administering the questionnaire to participants not fluent in English language. This could have introduced interviewer bias in spite of the training conducted for the interviewers before the workshop. The challenge was the lack of equivalent words or concepts for some expressions and this could have impacted on the respondent’s interpretation and understanding and therefore, their knowledge and attitude towards immunization.