"CHWs [community health workers] capitalised on their strong community role to educate community members, combat misinformation, conduct outreach and provide personalised service to caregivers."

As frontline health workers, community health workers (CHWs) play a key role in routine vaccination programming by generating demand for childhood vaccination, connecting community members to the formal healthcare system, and working closely with and in communities, schools, and religious facilities. With the continued projection of health worker shortages, especially in low-income countries, CHWs can bridge the equity gap in access to vaccination services by enabling wider reach to underserved populations. Conducted in Nepal, Senegal, and Zambia, this study sought to understand how CHWs are engaged for successful early childhood vaccination among countries that showed success in immunisation coverage, with the hope of supporting evidence-based policy guidance across contexts.

Nepal, Senegal, and Zambia were selected based on their success at achieving high and sustained growth in early childhood vaccination, based on historical (i.e., 2000-2018, up to the point of starting this project) diphtheria, tetanus, and pertussis vaccine (DTP) 1 and DTP3 coverage estimates. (See Related Summaries, below, for additional details.)

The research team was multidisciplinary, and the team ensured involvement of all stakeholders in the design, implementation and the dissemination of this project. The researchers conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility, and community levels of the health systems of Nepal, Senegal, and Zambia, from October 2019 to April 2021. They used thematic analysis to investigate contributing factors of CHW programming that supported early childhood immunisation within each country and across contexts.

Implementation of vaccination programming relied principally on:

1. CHW programming organisation: expanding cadres of CHWs to carry out their roles and responsibilities related to vaccination. Each country had different types of CHWs who played specific roles in immunisation programming. In Nepal, female community health volunteers (FCHVs) created awareness on immunisation and linked the communities to the healthcare facilities. Senegal had 5 different cadres (see table 3) involved in different aspects of immunisation. In Zambia, neighbourhood health committees (NHCs), safe motherhood action groups, and growth monitoring promoters played a critical role in improving vaccination coverage through the roles and responsibilities they held. Per the researchers, CHWs working together with other health workers and receiving required supervision could increase their confidence in work, and their motivation to work harder, thus improving their performance.
2. CHW motivation: providing CHWs with recognition, tangible incentives, capacity building, and empathy and compassion for their communities. CHWs in all 3 countries emphasised the meaning and value they found in their work. For example, in Nepal, FCHVs appreciated the recognition for their role in increasing vaccine coverage. Some FCHVs received certificates. Villages, districts and provinces were declared fully immunised and celebrated by the national government through the Full Immunisation Declaration (FID) Programme in a bottom-up approach, which motivated CHWs and volunteers and facilitated community buy-in to immunisation. Per the researchers, standardising CHWs compensation within different settings may be of value, which could be done through governments setting aside a funding stream dedicated to CHWs and considering other sources of funding to supplement existing sources.
3. Trust in CHWs: ensuring positive social capital and mutual trust through community engagement and knowledge sharing, as well as CHW respect and value placed on their work. CHWs were respected members of the community, with some individuals regarded as opinion leaders; this trust was facilitated by the selection of CHWs from the communities in which they lived. Examples:
   • In Nepal, FCHVs were required to work in the communities they resided in; CHWs reported that this positioning generated trust and enabled them to promote culturally and contextually appropriate messaging to diverse stakeholders. Health and immunisation education were presented in monthly meetings; content was selected and tailored depending on literacy, vulnerability to misinformation, and cultural norms.
   • In Senegal, one cadre of CHW, the bajenu gox, included multiple family members in educational outreach on vaccinations and maternal and child health. Bajenu gox held education groups for adolescent girls in addition to women of all ages to target misinformation and mediate between different age groups. In recent years, bajenu gox has also conducted outreach with fathers' groups, aiding in full family approval of childhood vaccinations. Trust between the health workers and the bajenu gox was enhanced through supportive supervision.
   • In Zambia, NHCs played a prominent role in community sensitisation, outreach, and vaccine education. They were a trusted source of information for community members since they were recruited by community leaders and worked closely with health facility staff to coordinate outreach sessions. Consistent follow-through of outreach sessions contributed to community members' trust in NHCs and, by extension, the health system. NHCs also worked to dispel myths and misconceptions about vaccinations by educating parents on the benefits.

   The engagement of CHWs and their communities and the frequent interactions CHWs had with their communities, especially with mothers, facilitated the understanding of social and cultural norms, which facilitated knowledge sharing and enhanced trust between the CHWs and the communities they served and the information they shared.

The researchers note that, although improvements in vaccination programming were seen in all 3 countries, CHWs faced challenges in providing adequate services in their communities. Workload, low and inconsistent compensation, inconsistency in training duration and scope, and supervision resulted in demotivation and high turnover of CHWs in all countries. As argued here, the governments need to adequately address issues related to the recognition of CHWs, especially their compensation. Based on their contexts, countries should focus more on ways of addressing such challenges, and country-specific research on strategies to ensure consistent funding for CHWs would be beneficial.

Going forward, "Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming."

Full list of authors, with institutional affiliations: Emily A Ogutu, Emory University; Anna S Ellis, Emory University; Kyra A Hester, Emory University; Katie Rodriguez, Emory University; Zoe Sakas, Emory University; Chandni Jaishwal, Emory University; Chenmua Yang, Emory University; Sameer Dixit, Centre for Molecular Dynamics; Anindya Sekhar Bose, World Health Organization (WHO); Moussa Sarr, Institut de Recherche en Santé, de Surveillance Epidemiologique et de Formations; William Kilembe, Center for Family Health Research; Robert Bednarczyk, Emory University; Matthew C Freeman, Emory University