Engaging Traditional Barbers to Identify and Refer Newborns for Routine Immunization Services in Sokoto, Nigeria: A Mixed Methods Evaluation

"...grounded in an understanding that social relationships within the community have a strong influence on health behaviors..."

United Nations Children's Fund (UNICEF) data indicated that, in 2017, only 3% of children in the northern Nigerian state of Sokoto received the third dose of pentavalent vaccine by their first birthday. Such worrisome statistics have been attributed to a variety of factors, including limited knowledge among mothers about the risks associated with not vaccinating their children, misinformation from rumours, distrust of the health system, and community norms. Recognising the value of two-way communication with trusted advisors, the Sokoto State Primary Health Care Development Agency (SPHCDA) developed a Community Partnership Strategy for routine immunisation (RI) that highlighted the importance of engaging community-based volunteers to increase community demand for and use of RI services. This study evaluates the effectiveness of an intervention that engaged traditional barbers ("Wanzams" in Hausa), to inform parents about the importance of vaccination and then refer newborns for vaccination services.

In northern Nigeria, traditional authorities became a key ally for the Polio Eradication Initiative (PEI) after the Sultan of Sokoto, a Muslim spiritual leader, publicly announced his support for the PEI. The traditional authorities operate within a hierarchical structure from the state down to the community level, where they engage directly with community leaders and traditional barbers' associations. In this context, in May 2018, the Maternal and Child Survival Program (MCSP), which is funded by the United States Agency for International Development (USAID), supported the SPHCDA to train 1,210 traditional barbers, who were selected by traditional authorities, along with orienting health providers and community leaders in 5 Local Government Areas (LGAs) in Sokoto to identify and refer newborns for RI; 844 barbers participated in the strategy.

The training focused on the importance of RI, how to counsel and educate a family about the benefit of immunisation through interpersonal communication, and the process of using colour-coded referral cards. SPHCDA encouraged traditional barbers to re-visit the family once to confirm compliance with the vaccination referral. This visit was not mandated, and there were no follow-up trainings or direct supervision. However, monthly meetings facilitated by health providers with traditional barbers and community representatives provided an opportunity for questions and feedback, and traditional barbers were encouraged to report defaulters to community leaders. SPHCDA program managers also monitored the number of each colour card distributed and recovered each month.

Figure 2 in the paper presents a Theory of Change (ToC) that describes how the strategy was expected to influence immunisation coverage. The strategy is grounded in the Health Belief Model (HBM), which recognises that parents will be more likely to vaccinate their child if they understand the severity of the vaccine-preventable illness, the suspectibility of their child to it, and the increased threat to their child if he or she is not immunised.

The study team administered a pre/post-quasi-experimental survey (n=2,639), with the baseline survey implemented before programme implementation in December 2017 and the endline survey administered at the conclusion of implementation in October-November 2018. Its purpose was to evaluate changes in the coverage of oral polio vaccine (OPV), Bacille Calmette-Guérin (BCG), and hepatitis B (HepB) vaccines among children aged 0-5 months in response to the intervention. The team also conducted 27 in-depth interviews (IDIs) and 21 focus group discussions (FGDs) to assess the enabling factors and challenges associated with implementation.

Quantitative findings indicated that:

• Compared to 5 LGAs that served as a control group, mothers who received a yellow referral card from a traditional barber were 2-3 times more likely to vaccinate their children with the 3 birth antigens.
• Exposure to the intervention was limited to 16% of mothers of infants interviewed, indicating that implementation challenges (see below) prevented the approach from fully reaching the intended population.
• At baseline, approximately 18% of women in both the intervention and the comparison groups had knowledge about the need to immunise a newborn within the first week of life. At endline, this figure increased to 39% in the intervention group (a 21% point increase), compared to 27% in the comparison group (a 9% point increase). Similarly, mothers' knowledge that a child should be vaccinated 5 times increased from 10.9% to 18.5% in the intervention group (7.6% points), compared to an increase of 11.8% to only 14.2% (2.4% points) in the comparison group.
• In the intervention group, there was a nearly 9% point increase in the number of mothers who believed that their child was more likely to get sick if he or she had not been vaccinated; this belief did not change between baseline and endline among mothers in the comparison group.

Qualitative findings indicated that:

• Parents trusted traditional barbers and found that the messages were shared consistently throughout the community - reinforcing their beliefs that the advice benefited a child's health.
• Both traditional barbers and parents commented on the importance of dialogue when discussing immunisations. Since mothers often must seek permission from the husband before taking the child to the health facility, the barber's contact with the father encourages his support as well.
• The linkages between the traditional community leaders and the barbers provide an added layer of support and trust.
• Challenges with the intervention stemmed from the low levels of literacy among community leaders and barbers, which resulted in the need for continuous training, low-literacy training materials, and supervision. Some trained traditional barbers did not participate in the programme after receiving training because they had anticipated but had not received a financial benefit for their effort. Also, in some cases, parents were resistant to traditional barbers' messages and refused to take their newborns for immunisations.

Based on the findings, some suggestions for future programmes in Nigeria include:

• Engage with community members through a participatory process to ensure that traditional barbers selected are those who are most frequently consulted by the community.
• Hold periodic refresher trainings to ensure that traditional barbers are able to accurately transmit messages on the immunisation schedule and antigens.
• Ensure that barbers are informed about their voluntary participation, and consider monetary and/or non-monetary incentives to encourage them to return to communities (especially remote ones) for a second visit.

In conclusion, the approach outlines here offers "lessons on how community resource partners such as traditional barbers can be leveraged to increase demand for vaccination services and address vaccine hesitancy particularly in a setting that has encountered resistance due to misinformation and rumors. Further research will be required to understand how implementation can be strengthened to reach a broader segment of the target population."