The ‘fifth child’ intervention has two objectives, which are 1) to improve access to quality data on immunization status, and 2) to utilise community engagement to trace defaulters and optimize outreaches.
Objective 1: to improve access to quality data on immunisation status by producing and integrating improved data on the number of infants in the catchment area and data from immunisation services at both fixed and outreach sites to create a user-friendly data platform on immunisation status.
The Fifth Child intervention starts in the community. Guided by IRC staff, Village Health Team members (VHTs) work with village leaders (e.g. local councillors and religious leaders) to register all children, 0-12 months, and continually add newborns to the cohort. Villages included in the intervention arm health facility catchment areas are clearly delineated and all the community-generated data on individual infant immunisation status is entered by the healthcare worker (HCW) into the mHealth tool containing the following programmatic applications:
• Comprehensive immunization register: when an infant is immunised either at the facility or an outreach session, data on the updated status of that child is easily uploaded into the single CommCare platform, (rather than relying on facility-based registers and outreach tally sheets that are rarely consolidated). Healthcare workers are encouraged to routinely review child immunisation cards at contact opportunities and update the mHealth tool since some infants may receive immunisations outside of the catchment area.
• Facilitated vaccine reminder and defaulter identification: Infants are registered by birth date and health facility staff can easily open the ‘Vaccine Reminder’ tab in the application that flags those infants in their catchment area with immunizations due in the next 5 days. A separate tab, maintains an up-to-date list of defaulting children, defined as having missed an immunisation by >14 days, (either based on their birth date or when the previous antigen was administered). This list can be easily sorted by parish, village, or VHTs responsible.
Objective 2: to utilise community engagement strategies to trace defaulters and optimize outreaches and thereby decrease the number of defaulters through systematic engagement with community leaders and other key community groups in outreach planning, mobilisation, and implementation, based on coverage data, and performance monitoring of defaulter-tracing.
The intervention aims to equip VHTs with the tools and techniques necessary to encourage caregivers to seek immunisation services. It hypothesizes that data informed defaulter tracing, VHT home visits and active engagement of community leaders e.g. local councillors will promote linkages between community members and health facilities that organise immunisation services and outreaches.
Community leaders, are most often local counsellors (LCs), but could also include religious leaders, women leaders, of villages where there are more than 5 defaulting children that month, are supported to review coverage data for their village and. actively participate in planning meetings and to help design and schedule the outreaches alongside VHTs and HCWs. This meeting for the planning of ‘smarter outreaches’ is held at the facility level and is conducted with the assumption that if outreaches are convenient, and based on the data showing where the most defaulters are, it is more likely that infants will be brought. This pathway also postulates that community co-management leads to strengthened linkages between the community and facility and increased community ownership and accountability of HCWs. An intended positive outcome in the short-term could be creation of community demand for other maternal and child health services and more referrals from community to facilities. Another possible intended outcome may be community participation in other last mile health services.
During monthly meetings, HCWs inform VHTs which infants in their villages are due for immunisation and share the list of defaulters. Based on the number of infants/village and estimated dropout rate, it is expected that each VHT will visit approximately 2-3 infants due for immunisation and 1-2 defaulters per month.
VHTs are trained on administering key immunisation messages, addressing myths and misconceptions and improved interpersonal communication skills for counselling that focuses on reasons why the child missed their immunisations. Home visits are intended to be interactive where VHTs facilitate caregivers and other household decision-makers to develop an action plan for catch-up immunisation. They inform caregivers the date, time, and location of the next outreaches in the catchment area and provide a referral ticket for immunization services either at facilities or outreaches. As defaulters present referral tickets, the infants are vaccinated and updates are entered into the data platform, the HCW and the project team are then able to examine the timeliness and rates of catch-up vaccination post home visits.
Formative findings suggest that VHTs are motivated for defaulter visits and outreach mobilisation because with improved data, their efforts target households most in need. Their community leaders are more aware of defaulters, more systematically involved in mobilisation and play a role in monitoring VHT efforts. This pathway assumes that if community leaders have individualised data on defaulters, this will capture their interest and they will become supportive co-managers aiming to protect their communities against vaccine-preventable disease.