Evaluating an Integrated Family-Based Vaccination Program in Sierra Leone

Background: Challenges and Strategies for Vaccine Uptake

• Declining Immunization Rates Before and During COVID-19 (2020) 

• The Role of Mobile Vaccine Teams in Improving Access (MoHS, UNICEF, GAVI) 

• Challenges in Vaccine Uptake Among Northern Districts (Karene, Koinadugu, Falaba) 

Even before the first case of COVID-19 in Sierra Leone in March 2020, immunization rates and the use of child health care services had declined by almost 19% ⁽¹⁾. The Ministry of Health and Sanitation (MoHS) in collaboration with GAVI, UNICEF, and the World Health Organization (WHO) worked throughout the COVID-19 pandemic to mitigate any further decline by supporting an innovative integrated life-course approach to vaccination ^{(1, 2)}. As part of this, mobile vaccine teams were deployed to bring education and vaccine access across the 16 districts of Sierra Leone. The mobile vaccine teams comprised MoHS public health workers, health worker vaccinators, data monitors and social mobilizers connected to the community ^{(1, 2)}. 

Under the integrated life-course approach, the mobile vaccination team focused beyond a singular vaccine for a particular condition, individual or demographic. Instead, the team assessed the entire household’s vaccination needs and provided vaccinations accordingly, for example, pentavalent vaccine for children, human papillomavirus vaccine (HPV) for youth, and COVID-19 vaccine for youth and adults. The innovative family-centered life-course strategy was found to have a positive synergistic effect across multiple vaccines. Immunization rates for vaccines, such as the pentavalent vaccine, returned to almost 90% for the third dose in most districts. 

Despite the success of the initiative, the MoHS identified districts in the Northern province of the country that continued to show low COVID-19 vaccine acceptance and uptake ⁽³⁾. These districts had 20–50% lower immunization rates than the rest of the population in Sierra Leone and included the districts of Karene, Koinadugu, and, Falaba. These districts also had lower overall life-course vaccine uptake prior to COVID-19. Community feedback indicated that these challenges are at least partially due to the nomadic lifestyle of the population, as well as the religious beliefs of some ethnic groups in the region. Another significant factor was the difficult-to-access, geographically isolated zones and rugged, undeveloped terrains that had to be navigated to reach individuals in these regions, further complicating access to vaccination services.  

In addition to these structural and infrastructure barriers, health workers in Sierra Leone have also faced increased physical and mental exhaustion since the COVID-19 pandemic. Health workers have had to navigate the risk of infection, the pain of themselves losing patients, family and colleagues, as well as a lack of mental health services that might help them address these burn out issues. Research has highlighted the importance of providing health workers with the knowledge and skills to effectively engage communities around vaccine acceptance. This is particularly important to build vaccine confidence, as health workers are noted as the main source of “trusted individuals” by the community. To better meet the needs of health workers in Sierra Leone, Loma Linda University in collaboration with the MoHS deployed the Community Resiliency Model together with shared decision-making techniques (called “CRM+”, hereafter) to help health workers improve their resilience, mental health and wellbeing, to address potential burn-out and better serve community members within their catchment areas by learning a more responsive engagement approach, that included self-care. 

This project, conducted by Loma Linda University, set out to evaluate the new MoHS integrated family-centered life-course approach to vaccine uptake and the impact of the CRM+ model in Sierra Leone. 

Research Objectives: Measuring the Impact of Vaccine Strategies

Aim 1: Evaluating Vaccine Uptake in Hard-to-Reach Populations 

• Evaluate the use of integrated family-centered life-course mobile vaccination teams to increase vaccine uptake among nomadic communities living in the Northern provinces of Sierra Leone. 

• Assess the cost and comparative cost-effectiveness of this approach through a) tracking the overall cost of the intervention and b) determining the cost-benefit of using mobile vaccination teams, as assessed by total US$ per averting an adult from being zero-dose or under-immunized, against a previous facility-based vaccination model for the uptake of the HPV vaccine. 

Aim 2: Strengthening Resiliency and Mental Wellbeing of Health Workers 

• Analyze the benefit of adding resiliency training for all team members and regularly embedding resiliency-trained persons in the mobile vaccination team, for the purpose of supporting social mobilizers with engagement and communication within their communities. 

• Analyze the benefit of adding a mobile vaccination team member with the task of supporting the resiliency, mental health and wellbeing of both mobile vaccination team members and the community groups they serve. 

Study Population and Location

Nomadic families living in the Northern province of Sierra Leone (Karene, Koinadugu, and Falaba) in areas with a vaccination uptake rate below 50%.

Methodology: Analyzing Vaccine Delivery and Impact 

This was a mixed-methods study evaluating the comparative effectiveness of an integrated family-centered life-course vaccination approach as well as the additive benefit of embedding a wellness team member with the mobile vaccination teams to support them.  

Aim 1: Evaluating the Effectiveness of a Family-Centered Life-Course Vaccination Initiative for Hard-to-Reach Populations in Sierra Leone Post-COVID-19. 

As part of Aim 1, the cost-benefit and cost-comparison of mobile vaccination units (MVUs) was calculated versus traditional static and outreach-based vaccination campaigns. The analysis also compared the cost-effectiveness of administering HPV vaccines through MVUs to the cost of screening and treating cervical cancer in the country. 

Vaccination data for 2023 were sourced from the Sierra Leone MoHS district health records, encompassing individuals vaccinated at static health facilities, outreach events, and Periodic Intensification of Routine Immunization (PIRI) events. Cost information was gathered for outreach/PIRI campaigns and MVUs, as well as per-dose vaccine costs. Data on mortality rates and the effectiveness of HPV vaccines were taken from international health databases. 

Aim 2: Assessing the Impact of Embedded Wellness Team Members on Vaccine Mobilization, Mental Health, and Community Resilience in Sierra Leone 

Community participants who attended vaccination outreach events were asked to complete a post-vaccination survey. The survey was designed to assess various aspects related to the participants’ knowledge and attitudes toward vaccination. This included the likelihood of themselves or their children getting vaccinated, the difficulties they experienced in accessing vaccination services, and the influential individuals or entities that impacted their decision to receive vaccines.  

The study also evaluated the impact of embedding a wellness team member trained in CRM+ skills within MVUs. The intervention aimed to support social mobilizers and enhance the resilience, mental health, and overall wellbeing of the mobile vaccination team members and the community members they served. The Loma Linda University research team worked closely with the MoHS to select 6 of the teams working with nomadic populations in the Northern provinces and embedded a wellness team member with these teams. An additional 6 teams working in the same region and population were randomly selected to form the comparison group. At the start of the intervention, mobile vaccination teams took part in a 2-day CRM+ training. 

A stepped-wedge design was utilized to evaluate outcomes, comparing data collected from pre- and post-intervention phases. Researchers compared the resiliency, mental health, wellbeing, engagement and communication skills of MVU team members with and without an embedded wellness team member. The following measures were used to evaluate these factors: 

• Multidimensional Assessment of Interoceptive Awareness: Assesses participants’ internal body awareness and their ability to perceive bodily signals. 

• Difficulties in Emotion Regulation Scale – 8 items (DERS-8): Evaluates participants’ ability to regulate emotions, measuring aspects like emotional awareness and impulse control. 
• Copenhagen Burnout Inventory (CBI-13): A 13-item scale assessing burnout levels in personal, work-related, and client-related domains to understand how participants cope with stress in their roles on the MVU. 

Sampling Approach for Vaccine Impact Analysis

A purposive sampling method was used to select the three northern districts, based on their historically low vaccination rates. Within each region, the Ministry of Health and Sanitation (MoHS) provided a list of eligible Mobile Vaccination Unit (MVU) sites and teams. From these, two sites and their corresponding teams were randomly selected per district. Mobile teams and their vaccine recipient sub-samples were then recruited for Aim 2. Wellness team members were then assigned to MVUs and traveled with them to their designated catchment areas.

Data analysis 

For Aim 1, the cost per vaccinated individual was calculated by dividing the total operational cost by the number of vaccinated individuals during outreach/PIRI campaigns. Costs for the comparison of single versus multi-vaccine campaigns were distributed over 5 to 13 types of vaccines to evaluate cost per dose. For the calculation of MVUs cost versus cost of cervical cancer treatment, the average number vaccinated per MVU trip was used to project per-person vaccination costs. This was compared with the screening and treatment expenses for cervical cancer. Potential lives saved were estimated using population data for the Karene, Koinadugu, and Falaba districts for vaccine-eligible women within the 10–19 age group and the efficacy rate of the HPV vaccine. 

For the community survey under Aim 2, descriptive analysis was used to summarize the data collected. This included the frequencies, percentages, means, and standard deviations for the key variables related to knowledge, vaccination likelihood, perceived difficulties, and influential factors.  

Repeated measures Analysis of Variance (ANOVA) was used to assess the impact of including a wellness team member on MVUs and its effect on participants’ interceptive awareness, emotional regulation and symptoms of burnout. The research employed a step-wedge design with data collected across three time points. At Time Point 1, both intervention and control groups completed a baseline survey. Time Point 2 assessed post-intervention results for the intervention group, while the control group completed the survey without intervention. The control group was then given the CRM+ skills training. At Time Point 3, both groups had received the intervention and completed follow-up assessments.

Impact of the Family-Centered Approach on Immunization Rates 

• Effectiveness of Multi-Vaccine Campaigns in Reducing Costs (US$ 0.95 per vaccine) 

• Projected Public Health Benefits of Increased HPV Vaccine Coverage (HPV Coverage: 70%+) 

The analysis of vaccination campaigns and associated costs in the northern rural districts of Sierra Leone revealed distinct differences in the efficiency and cost-effectiveness of various strategies. In 2023, static facility vaccinations reached fewer individuals compared with outreach and PIRI events, with Karene reporting 335 individuals at static facilities versus 1808 and 2045 individuals through outreach and PIRI events, respectively. Similar trends were observed in Koinadugu and Falaba. 

The cost analysis indicated significant advantages for multi-vaccine campaigns. For instance, in Karene, the per-individual cost for a single-vaccine outreach was approximately US $4.75, whereas administering five types of vaccines during a single outreach reduced the per-vaccine cost to US$ 0.95. Comparable reductions were seen in Koinadugu and Falaba, demonstrating that distributing fixed operational costs across multiple vaccines can markedly enhance cost-efficiency. 

A comparative analysis of HPV vaccination cost via MVUs versus cervical cancer treatment highlighted notable preventive savings. The cost per vaccinated individual using MVUs was estimated by dividing the total cost per trip (US$ 1,078) by the number of individuals vaccinated, which typically ranged between 50 and 80, resulting in a per-person cost of approximately US$ 13.48 to US$ 21.56, encompassing vaccine doses and operational expenses. This was substantially lower than the combined cost of screening (US$ 862.59 per person) and treatment for cervical cancer, which ranged from US $1,521 to US$ 2,521 in-country and US$ 3,396 to US$ 4,396 out-of-country. 

The potential impact on public health was evident in the projected number of protected individuals. With 70% coverage and near 100% vaccine efficacy, an estimated 59,757 individuals in Karene, 49,313 in Koinadugu, and 40,627 in Falaba would be protected from HPV-related diseases, underscoring the potential reduction in HPV-related mortality. 

Improving Health Worker Resilience and Community Trust 

• Mental Health and Burnout Prevention Among Mobile Teams (CBI-13 Scale) 

• Community Perceptions of Vaccination Accessibility and Barriers (Survey Data & Focus Groups) 

Community survey

The demographic characteristics of community participants are provided in Table 1. Overall, 39.3% of community participants and 85.5% of their children received vaccination on the day of the community survey. 

Table 1. Demographic characteristics of community participants 

The analysis of participants’ knowledge and attitudes toward vaccination revealed that almost all respondents (99.5%) knew where their local health clinic was located for receiving vaccinations. Regarding the likelihood of obtaining routine child vaccinations, the responses varied: 51.4% reported being “extremely likely,” 36.4% as “somewhat likely,” and 3.7% as “not at all likely”. 

Attitudes toward COVID-19 vaccinations showed that 51.4% were “extremely likely” to receive it, 30.8% were “somewhat likely,” and 9.3% were “not at all likely (Figure 1). For the HPV vaccine for children, 60.3% were “extremely likely,” 28.0% were “somewhat likely,” and 2.3% were “not at all likely,” while 9.3% reported it as not applicable. When asked about vaccines recommended for adults, 51.4% indicated they were “extremely likely” to receive them, 26.6% were “somewhat likely,” and 14.5% were “not at all likely. 

Figure 1. Community member post vaccination engagement reports on whether they would have received vaccination without PIRI and MVU outreach efforts

In terms of how likely participants would have been to get vaccinated if the MoHS vaccination team had not set up the outreach, 46.3% indicated that they were “extremely likely,” to still get vaccinated, 30.4% said they were “somewhat likely,” to get vaccinated and 13.6% reported that they were “not at all likely” to still get vaccinated. Regarding child vaccinations without the MoHS team’s visit, 51.9% reported they were “extremely likely,” 26.6% were “somewhat likely,” 15.4% were “not at all likely to get their child vaccinated.

The analysis of barriers to vaccination revealed that although 60.3% of participants found it “not difficult at all” to get vaccinated, almost 40% of participants reported finding it “somewhat difficult” or “extremely difficult” to go get vaccinated (Table 2). The most commonly reported reasons for difficulty were distance and transportation challenges to vaccination sites, with 41.6% of participants indicating that it was “too far away” 35.0% noting a lack of transportation and 18.7% reporting “cost of travel” as a barrier.

Table 2. Reported difficulties in accessing vaccinations

Mobile Vaccination Unit (MVU) intervention

The demographic characteristics of MVU participants are provided in Table 3. Overall, MVU’s were primarily comprised of community health workers (31.6%), community leaders/stakeholders (29.9%), and social mobilizers (19.5%).

Table 3. Demographic characteristics of mobile vaccination unit participants (N = 231)

MVU, mobile vaccination units.

The analysis of baseline and post-training responses highlights the perceived positive impact of including a wellness team member on the MVUs. Pre-intervention results showed that most MVU team members believed that having a wellness team member would have a positive impact on the MVUs. At baseline, most respondents (88.3%) believed that having a wellness team would help them do their job better. However, there was some apprehension on the benefits of a wellness team member, with 9.5% of participants indicating “not true” or “somewhat not true” to the prompt “helps me do my job better”. A further 7.4% disagreed that a wellness team member “helps reduce my work stress,” and 10.8% disagreed that a wellness team member “helps reduce my personal stress.” However, post-intervention data revealed a positive shift in all categories (Figure 2).

Figure 2. Participant opinions on the impact of a wellness team member on the MVU (pre- and post-intervention)

At baseline, mean interoceptive awareness scores (a measure of wellbeing) were similar between the intervention group (M = 25.51, SD = 7.29) and the control group (M = 25.00, SD = 7.35). Post-intervention at Time Point 2, the intervention group showed a significant increase in interoceptive awareness (M = 34.76, SD = 6.07), while the control group, which had not yet received the intervention, showed a more modest mean interoceptive awareness score (M = 27.24, SD = 6.91). At Time Point 3, after the control group also received the intervention, scores were similar between the intervention group (M = 33.47, SD = 4.90) and the control group (M = 34.18, SD = 4.85).

However, while the inclusion of a wellness team member on the MVUs did slightly increase mean participant emotional regulation as measured by the DERS-8, the difference was not statistically significant. There was a modest, but significant decrease in burnout levels, as measured by the Copenhagen Burnout Inventory, from pre- to post-intervention (p=0.037) for the intervention group.

Recommendations

• Targeted funding should be allocated to support multi-vaccine outreach programs, which have been demonstrated to be more cost-effective than single-vaccine campaigns. By distributing the operational costs across multiple vaccines, the overall expenses per vaccine can be minimized, allowing for a broader and more financially sustainable public health strategy.
• Policies should advocate for the broader use of MVUs in rural and hard-to-reach areas to increase vaccination coverage. Investing in MVUs can be a strategic move to reduce long-term healthcare expenses and improve health equity, given the preventive savings demonstrated through HPV vaccination compared with cervical cancer treatment costs.
• The findings support the integration of wellness strategies in healthcare settings to mitigate burnout. However, further research with a larger sample size and a longer follow-up period would be valuable to provide greater insights into the long-term effectiveness of integrating a wellness team member within MVU units. An alternative strategy may be to incorporate wellness skills training into their other job-related trainings.

Conclusions

Together, the findings underline the value of the integrated family-based vaccination program to support vaccine uptake in vaccine-hesitant populations in Sierra Leone. The cost-benefit analysis supports the expansion of MVU programs and multi-vaccine outreach efforts as practical and economical public health strategies to expand vaccination coverage. The potential to avert costly treatments and improve health outcomes justifies continued investment in vaccination campaigns, particularly in resource-limited settings.

This study also demonstrates that wellness team members can significantly enhance both the work environment and personal stress management for healthcare staff in high-demand settings. The findings suggest that including a wellness team member in MVUs may support their wellbeing and stress management. Applying the approach utilized here, of an integrated family-based vaccination program, delivered via MVUs with embedded wellness team member, could be considered for other vaccine-hesitant and hard to access populations.

References

1. World Health Organization. Sierra Leone reversing immunization decline in wake of COVID-19 2020 [Available from: https://reliefweb.int/report/sierra-leone/sierra-leone-reversing-immunization-decline-wake-covid-19.
2. Worldwide C. Redefining access: COVID-19 vaccine delivery in Sierra Leone 2022 [Available from: https://www.concern.net/knowledge-hub/redefining-access-covid-19-vaccine-delivery-sierra-leone.
3. Ministry of Health and Sanitation. COVID-19 Vaccination TWG Meeting. Child Health/EPI Program. Government of Sierra Leone Ministry of Health and Sanitation. 2022.