Improving Hepatitis B Birth Dose Coverage through Village Health Volunteer Training and Pregnant Women Education

"The results of this project suggest that coverage of hepatitis B birth dose vaccination can be improved by strengthening the linkage between health workers and communities and by using these groups to educate caregivers."

The major cause of liver cancer globally, chronic hepatitis B infection is highly endemic in the Republic of Kiribati. Meanwhile, the coverage of timely birth dose vaccination, the primary method shown to prevent mother-to-child transmission of hepatitis B virus, was only 66% in 2014. Children born at home are especially at high risk, as they have limited access to timely birth dose (i.e., within 24 hours) vaccination. The primary objective of the project described in this article was to assess whether a training package that included educating pregnant women and improving linkages between village health volunteers (VHVs) and health facilities would improve birth dose coverage in areas with low coverage in Kiribati.

Sixteen community health centres with birth dose vaccination coverage of less than 70% among infants were selected for the project, which was conducted from November 2014 through April 2015. Training workshops were held to educate health workers and VHVs on the project and their responsibilities. Health workers included nurses, nurses' aides, and medical assistants working in community health facilities. VHVs included health volunteers working in the communities prior to the project, traditional birth attendants, and members of village welfare groups.

As part of the intervention, health workers conducted monthly meetings with pregnant women in their communities. VHVs conducted monthly household visits to all pregnant women in their communities to register their pregnancies and to encourage antenatal care visits, delivery in health facilities, and birth dose vaccination. Health workers and VHVs educated pregnant women on hepatitis B transmission, the long-term effects of chronic hepatitis B infection, and planning for delivery in health facilities and for birth dose vaccination.

In order to enhance the linkage between communities and health facilities, health workers and VHVs were instructed to hold monthly meetings to review education activities in the communities, update pregnancy registers, and discuss problems encountered in vaccinating newly born babies. VHVs were asked to share the lists of pregnant women with community health facilities on a monthly basis and to immediately inform health facility staff of any women who were in labour in their communities. Health workers were instructed to take the vaccine outside the cold chain (e.g. to take the vaccine without using a cold box) to provide outreach vaccination to babies delivered at home.

Prior to project implementation, a baseline survey was conducted in October 2014 to measure knowledge and practice among health workers, all VHVs and all caregivers, usually the mothers, of infants born within 12 months before the baseline in the catchment areas of selected health facilities. Six months after implementation of the project, a follow-up survey was conducted among health workers, all VHVs, and all caregivers of infants born during the project to assess changes in knowledge and practices and determine project impact.

The coverage of timely birth dose administration increased significantly - both in the densely populated capital region of South Tarawa (from 89% to 95%, p = 0.001) and the Outer Islands (from 57% to 83%, p < 0.001). The coverage of timely birth dose administration among infants born at home increased significantly from 70% to 84% in South Tarawa (p = 0.001) and from 49% to 75% in the Outer Islands (p < 0.001).

Timely birth dose was associated with being born in a hospital, being born during the study period, and caregivers having developed an antenatal birth dose plan. No significant changes in coverage of other routine immunizations were observed during the project period (Bacillus Calmette-Guérin (BCG) vaccine, oral polio vaccine (OPV), pentavalent vaccine, pneumococcal conjugate vaccine), with the exception of a slight but significant decrease in coverage with 3 doses of pentavalent vaccine in South Tarawa.

Findings from baseline and follow-up surveys of knowledge of hepatitis B among caregivers are summarised in Table 2. Significant increases in percentages of caregivers reporting having heard of hepatitis B and the vaccine and knowing timing of the birth dose were observed in the Outer Islands, but not in South Tarawa. Overall, 47% of caregivers knew hepatitis can cause jaundice, while few could name long-term outcomes of hepatitis B.

In the Outer Islands, significant increases were observed in percentages of caregivers who reported being advised to deliver at health facilities during antenatal visits (from 64% to 89%, p < 0.05), being told about hepatitis B during antenatal visits (from 21% to 34%, p < 0.05), discussing planning for birth dose vaccination during antenatal visits (from 29% to 70%, p < 0.05), receiving a home visit by a health volunteer about hepatitis B (from 29% to 70%, p < 0.05), and attending a community meeting where hepatitis B vaccination was discussed (from 9% to 39%, p < 0.05). However, among caregivers in South Tarawa, there were decreases in the percentages for all of these educational messages/activities with the exception of attending a community meeting where hepatitis B vaccination was discussed, for which there was a nonsignificant increase.

Findings from baseline and follow-up surveys of health workers' practices on birth dose vaccination and vaccine management are summarised in Table 4. After the project, the overall percentage of health workers who delayed vaccination due to false contraindications (prematurity or low birth weight) decreased from 100% to 38%. At follow-up, 88% health workers knew there was a VHV for their health facilities, compared to 50% at baseline. The percentages of health workers who met with VHVs weekly or monthly increased from 40% to 82% in the Outer Islands and from 0% to 40% in South Tarawa. The percentage of health workers who were informed of home deliveries increased from 30% to 91% in the Outer Islands and from 25% to 60% in South Tarawa.

In short, "Substantial improvements in hepatitis B birth dose coverage were seen during the project period. These increases paralleled strengthened linkages between community and health facilities and improved knowledge and practices among VHVs. Before the project, only 5% of VHVs reported keeping a list of pregnant women in their villages and sharing the information with local health facilities, whereas at the conclusion of the project, almost three-quarters of VHVs reported they informed health facilities of pregnancies in their communities. At follow-up, there was an 8-fold increase the percentage of VHVs who received hepatitis B training from local health facilities. VHVs showed substantial improvements in knowledge on hepatitis B disease and transmission, and a 2-fold increase in the percentage of volunteers who knew that hepatitis B vaccine should be given within 24 h after birth. These changes may help explain the increase in the coverage of timely hepatitis B birth doses during the project period when coverage of other routine vaccines largely remained unchanged."

The differences in findings seen in the Outer Islands as compared to South Tarawa can be explained perhaps by the larger numbers of patients served and, likely, higher workload, in facilities in South Tarawa, which may have led to reduced opportunities for communication between health workers and VHVs and reduced opportunities for health workers to have organised community education sessions there. In the future, routine distribution of printed materials during antenatal visits or other mass media campaigns involving radio, television, or newspapers might assist those health facilities that have difficulties in conducting regular community education sessions.

In response to findings from this project, Kiribati conducted a national training among nurses on hepatitis B vaccination focusing on vaccine management and health communication in December 2015.

"This project provides a model to improve hepatitis B vaccine birth dose coverage that might be adopted by other areas in Kiribati, similar settings in the Pacific Islands and elsewhere."