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Objective To evaluate a project that integrated essential primary health-care services into the oral polio vaccine programme in hard-to-reach, underserved communities in northern Nigeria. Methods In 2013, Nigeria’s polio emergency operation centre adopted a new approach to rapidly raise polio immunity and reduce newborn, child and maternal morbidity and mortality. We identified, trained and equipped eighty-four mobile health teams to provide free vaccination and primary-care services in 3176 hard-to-reach settlements. We conducted cross-sectional surveys of women of childbearing age in households with children younger than 5 years, in 317 randomly selected settlements, pre-and post-intervention (March 2014 and November 2015, respectively). Findings From June 2014 to September 2015 mobile health teams delivered 2 979 408 doses of oral polio vaccine and dewormed 1 562 640 children younger than 5 years old; performed 676 678 antenatal consultations and treated 1 682 671 illnesses in women and children, including pneumonia, diarrhoea and malaria. The baseline survey found that 758 (19.6%) of 3872 children younger than 5 years had routine immunization cards and 690/3872 (17.8%) were fully immunized for their age. The endline survey found 1757/3575 children (49.1%) with routine immunization cards and 1750 (49.0%) fully immunized. Children vaccinated with 3 or more doses of oral polio vaccine increased from 2133 (55.1%) to 2666 (74.6%). Households’ use of mobile health services in the previous 6 months increased from 509/1472 (34.6%) to 2060/2426(84.9%). Conclusion Integrating routine primary-care services into polio eradication activities in Nigeria resulted in increased coverage for supplemental oral polio vaccine doses and essential maternal, newborn and child health interventions.
We implemented the project for 18 months between 1 June 2014 and 30 September 2015. The project proposed to expand on an existing mobile outreach strategy for routine immunization that was part of Nigeria’s national policy but not consistently implemented. The enhanced strategy provided routine immunization together with a basic integrated package of primary health-care interventions focused on maternal, newborn and child health. The emergency operations centre selected a total of 3176 settlements in six northern states (Bauchi, Borno, Kaduna, Kano, Katsina and Yobe). Hard-to-reach settlements were communities that had geographically difficult terrain with any local or state border, scattered households, nomadic populations, waterlogged or riverine areas, or where it was difficult to access the health-care facilities due to insecurity. UNICEF managed implementation in Kaduna and Katsina, and WHO managed implementation in Bauchi, Borno, Kano and Yobe. Each of the 84 mobile health teams comprised at least one nurse or midwife, a community health extension worker and a health records assistant. Staff were identified, trained and equipped with weighing scales, stethoscope, health commodities (e.g. essential drugs and consumables as contained in the UNICEF Emergency Health Kit) and recording tools. The 3-day training was provided within each state by facilitators using materials adapted from the Integrated Management of Childhood Illnesses and the Maternal, Neonatal and Child Health Week modules, with opportunities for refresher sessions during regular, monthly review meetings. Each team was assigned a specific number of settlements. Teams conducted mobile outreach visits to three to four settlements each week, and were expected to visit their assigned settlements once every 3 months. Their salaries were paid directly by UNICEF and WHO under non-staff consultancy contracts. The teams coordinated closely with local health-care personnel and the community. They worked directly with the routine immunization focal person of the health facility in the settlement catchment area. Volunteer community mobilizers, usually women from the settlements, were engaged and paid a small stipend to announce the outreach dates and promote basic public health behaviours. These volunteers were trained in their respective wards of residence on community engagement and defaulter tracking. The project also provided funds for transportation to the teams depending on route conditions (e.g. to hire four-wheel drive vehicle, motorcycle or boat). Team movements were monitored by local government facilitators, using checklists and mobile devices (a geographical information tracking system), which showed real-time movements for the purposes of monitoring settlement coverage and team security. Supervisors from partner organizations and the government project focal persons made supervisory field visits. There was an established programme review through monthly and quarterly review meetings at the state and subnational levels, respectively. We summarized the records generated during each outreach session (numbers of children vaccinated, vitamin A provided, children dewormed and nutritional screenings done; numbers of people seen and treated for ailments) and sent them via mobile devices to a server domiciled with an independent geographical information system provider. Weekly summaries were collated to monitor the sessions conducted and coverage of services; and transmitted to the local and state government levels. During the mobile outreach sessions, women and children in hard-to-reach settlements received a range of integrated health services. For example, pregnant women received antenatal care, malaria preventive therapy, iron folate, tetanus toxoid vaccine and treatment of illnesses (e.g. malaria and respiratory infections) or referral for care. Children aged 0–59 months received a full complement of routine immunizations (including oral polio vaccine), vitamin A supplements, deworming, diagnosis and referral for malnutrition, treatment of diarrhoea, pneumonia and malaria and additional referrals as required. In addition, all women attending outreach session were provided with health education on key household practices (hand washing, personal hygiene and infant feeding including exclusive breastfeeding). To assess changes in coverage for polio immunization and maternal, newborn and child health services, we conducted cross-sectional surveys at the start (baseline, March 2014) and after the implementation of the project (endline, November 2015). We used a simple random sampling method to select 317 (10%) of the 3176 hard-to-reach settlements where the project was implemented. A cross-sectional survey was made of women of childbearing age (15–49 years) in households containing at least one child aged 0–59 months (10 households in each settlement). In selected settlements with 10 or less households, all the households in the settlement were sampled and if 10 eligible mothers were not obtained, the surveyor moves to the nearest settlement within the same local government area and completed the process. In selected settlements with more than 10 households, the surveyor randomly selected the first household to be sampled and continued in a systematic way until 10 eligible mothers were obtained. A total of 206 independent, trained surveyors administer the standardized questionnaires. The questionnaire asked about the women’s demographic characteristics; knowledge of common preventable diseases; household’s access to services and coverage; and household member’s use of the mobile health sessions in their communities. The women were also asked about vaccinations for children younger than 5 years old in the household. Interviewers asked to see the vaccination card and records of polio vaccinations, asked the reason why any child had not been vaccinated and verified children’s tuberculosis vaccine scars. Surveys were administered over a period of 7–10 days at baseline (15–24 March 2014) and endline (3–16 October 2015). Due to population dynamics, for example, nomadic populations and displacement due to insecurity, the survey participants were not the same at baseline and endline. Households and respondents were not included in our second survey if they had not lived in the community for more than 6 months. Similarly, the settlements were not always the same, but must have been in the sampling frame, i.e. the selected settlements where the intervention was implemented. We also collected data from the project records on the services provided during the mobile outreaches session, which included summaries of children vaccinated, numbers of clients seen and the diseases treated. Analysis for the baseline and endline surveys were conducted separately to determine outcomes and to evaluate the integration of services. Analyses included comparisons of reported data across the six states during the studied periods. Descriptive analyses were used to compare information across the selected variables. The surveys formed part of the monitoring and evaluation activities of the Hard-to-Reach communities project, that was not intended as research work, but instead as an intervention to improve vaccination uptake among hard-to-reach communities. However, the government of Nigeria approved the project as part of the Global Polio Eradication Initiative activities to achieve the goals of the national polio eradication emergency plans and granted permission for the activities in the project. We obtained ethical clearance from the Bauchi state health research ethics committee. The survey assistants obtained informed consent from each survey participant after interpreting and explaining the consent section of the questionnaire in the participant’s local language. Those who gave their consent continued with the interview.
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