Integrating Immunization with Community-Based Management of Acute Malnutrition to Reduce Zero-Dose Children in Kano State, Nigeria

Background

In Nigeria, zero-dose children — those who have never received any routine vaccine — remain a significant challenge, particularly in underserved communities. The situation worsened during the COVID-19 pandemic, which disrupted routine immunization services and exacerbated vaccine hesitancy due to misinformation. Kano State, with its high population density and cultural complexities, was identified as a high-risk area for zero-dose children.

To address this, Omaiye Benson Igoche, Technical Officer/Epidemiologist at the African Field Epidemiology Network (AFENET) implemented the “Catch Them Young” project from March 1 to May 30, 2024, as part of the second cohort of Sabin and the World Health Organization’s  COVID-19 Recovery for Routine Immunization Fellowship Program. The project aimed to reduce the zero-dose rate by integrating routine immunization (RI) with the Community-Based Management of Acute Malnutrition (CMAM) program at the Unguwa Uku Primary Healthcare Centre in Taurani LGA, Kano State. This approach sought to create synergies between nutrition and immunization programs, leveraging community engagement to enhance vaccine uptake.

The integration strategy was inspired by learnings from Phase 1 of the fellowship, particularly on health system integration and community engagement. It focused on optimizing resource utilization, minimizing duplication of services, and ensuring culturally appropriate delivery of immunization messages.

Objectives

The project aimed to:

1. Improve Immunization Coverage: Integrate RI with CMAM to reduce zero-dose children by ensuring that immunization services were available alongside nutrition interventions
2. Address Vaccine Hesitancy and Myths: Use culturally tailored communication strategies to counter misconceptions about vaccines
3. Enhance Health Workforce Capacity: Build the capacity of health care workers to deliver integrated services and use data for decision-making

Implementation Strategy

Stakeholder Engagement and Advocacy 
The project started with advocacy and sensitization meetings with key stakeholders, including:

• State Director for Immunization
• Director of Public Health
• Head of the Medical Team for Médecins Sans Frontières (MSF)
• Program Manager for SERIC (State Emergency Routine Immunization Coordination)
• Community leaders
• These meetings aimed to secure buy-in, obtain necessary approvals, and ensure community support for the integrated approach

Capacity Building for Health Workers
A baseline assessment was conducted to evaluate the capacity and competency of healthcare workers (HCWs) using a written test covering key thematic areas in immunization. Gaps identified from the assessment informed the design of a targeted training program, delivered by:

• The Project Coordinator
• Facility RI Focal Person
• Facility In-Charge

The training covered:

• Cold chain management and vaccine storage
• Communication techniques to address vaccine hesitancy
• Data collection and tracking using electronic tool

Seven HCWs were recruited, including two supervisors, two vaccinators, two recorders, one town announcer, and one health promotion officer.

Integration of Immunization and Nutrition Services
The project integrated immunization services at the point of nutrition service delivery. Key activities included:

• Vaccine Tracking Mechanism: At the Community Based Management of Acute Malnutrition (CMAM) food distribution point, a screener and recorder checked immunization cards and interviewed caregivers to identify zero-dose children. This approach maximized the opportunity for immunization while caregivers accessed nutrition services.
• Heart-to-Heart Engagement: Caregivers were engaged in one-on-one discussions to build trust and address concerns about vaccination. This approach aimed to convert caregivers into community ambassadors, promoting vaccination within their social circles.
• Daily Audio/Video Display: Televisions were installed at the waiting area, playing key messages on the importance of vaccination, consequences of non-vaccination, and myths surrounding vaccines. These messages were presented in Hausa, the local language, for effective communication.

Community Awareness and Demand Generation
Community demand for immunization was enhanced through targeted awareness campaigns. The town announcer and health promotion officer conducted door-to-door sensitization, using culturally appropriate communication methods. Community influencers, including traditional and religious leaders, were engaged to reinforce positive vaccination messages. Special emphasis was placed on dispelling myths, such as misconceptions linking vaccines to infertility or severe side effects.

Challenges and Adjustments

1. Ethical Clearance Delays: Securing ethical clearance delayed the project’s start. More engagement with the State Ministry of Health was required to resolve this issue
2. Workforce Shortages and Congestion: The high turnout at the nutrition clinic led to congestion at the screening point. Additional personnel, including a supervisor, recorder, and vaccinator, were recruited to manage the increased workload
3. Unplanned Costs: The project incurred additional expenses for ethical clearance, mobile data for electronic data collection, and transportation. These were not initially budgeted, impacting overall financial planning

Outcomes and Impact

1. Increased Immunization Coverage: A total of 497 zero-dose children were identified and vaccinated with appropriate antigens across 33 Local Government Areas (LGAs). Immunization coverage improved significantly, particularly for key antigens such as Measles 1, Measles 2, and Yellow Fever vaccines (Figure 1).
2. Enhanced Community Acceptance: The integrated approach led to high vaccine acceptance, demonstrating the effectiveness of combining immunization with nutrition services. Feedback from caregivers indicated increased trust in vaccines, largely due to heart-to-heart discussions and the influence of respected community leaders.
3. Capacity Building: Health workers reported improved skills in cold chain management, communication to address vaccine hesitancy, and vaccine administration. Regular technical support enhanced the team’s efficiency in data reporting and service delivery.

Table 1. Social Demographic Characteristics of Caregivers and Children at Uguwa Uku PHC, Kano State, Nigeria

Table 2. Showing the Number of Children Immunized Before and After Intervention (TABLE ON WRITE-UP has a blue thick line in between columns Feb and March)

Figure 1. Immunization Coverage Before and After Intervention at Unguwa Uku PHC, Kano State, Nigeria

Table 3. Number of Zero Dose by LGA Identified at Uguwu Uku PHC, Kano State, Nigeria

Lessons Learned

1. Integrated Service Delivery is Effective: Combining immunization with nutrition services enhances immunization coverage and provides a holistic approach to child health
2. Community-Centric Communication Works: Using culturally appropriate messaging and leveraging community influencers effectively addressed vaccine hesitancy
3. Health Workforce Empowerment is Key: Ongoing training and technical support significantly improved health workers’ capacity to deliver integrated services
4. Flexibility and Adaptation: The project’s ability to adapt to challenges, such as ethical delays and workforce shortages, was crucial for successful implementation

Recommendations

Building on the project’s success, the following steps are planned:

• Scaling Up Integration: Advocate for the integration of immunization and nutrition services across all CMAM sites in Kano State
• Policy Advocacy: Collaborate with the Kano State Ministry of Health to formulate an integration policy for routine immunization and nutrition programs
• Sustainability and Expansion: Develop a sustainability plan to engage partners such as AFENET, Solina Center for International Development and Research (SCIDaR), and Médecins Sans Frontières (MSF) for long-term support and expansion to other LGAs

Conclusion

The “Catch Them Young” project demonstrated the effectiveness of an integrated approach to reducing zero-dose children by combining immunization with community-based nutrition programs. By leveraging community trust and delivering culturally appropriate communication, the initiative not only improved immunization coverage but also addressed the behavioral and social drivers of vaccine hesitancy. The success of this model offers valuable lessons for similar contexts across Nigeria and beyond.

References and Useful Links 

Behavioral and Social Drivers (BeSD) Framework: WHO BeSD Guide 
Integration of Immunization and Nutrition Services: Gavi’s Approach to Integration