Qualitative data collection

Qualitative data were collected at the national, regional, district, health facility and community levels. Data collection was from August 2019 to April 2021. The interview guides were informed by the Consolidated Framework for Implementation Research and the Context and Implementation of Complex Interventions frameworks.19 20 KII and FGD guides were translated into national and regional languages by research assistants, piloted by the research assistants among themselves before use and adjusted iteratively throughout data collection. An initial list of KIIs was developed with local research partners and MoH officials; snowball sampling was used to identify additional key informants. Sample size was determined by the point of saturation, when in-depth understanding of issues from the interviews was gained, and no new information was noted from the KIIs and FGDs.21 Caregivers and CHWs were recruited for FGDs from health facility catchment areas with the assistance of local health staff. The duration of KIIs and FGDs averaged one and a half hours. KIIs and FGDs were conducted in Nepali in Nepal, French in Senegal and Bemba in Zambia. KIIs and FGDs were audiorecorded with the permission of participants. Transcripts were translated to English manually or by using Google Translate (for French) and verified by fluent bilingual speaker. Research files, recordings and transcriptions were deidentified, password protected and kept on a secure server. The activities are summarised in table 2.

Data analysis

We applied thematic analysis to identify the contribution of CHWs in the success of childhood immunisation in Nepal, Senegal and Zambia. Emory researchers developed codebook inductively using emerging themes, and deductively using themes from CHW frameworks from previous studies, coded the transcripts and analysed data using MaxQDA2020 software (Berlin, Germany). The coding team met frequently, discussed emerging themes and clarified discrepancies within the codes. The researchers then categorised the themes within the broader domains of organisation, motivation and trust (table 1). Topic guides and codebooks used for data collection and analysis are attached in the (online supplemental appendix 122 and online supplemental appendix 2.

Cadre

Each country had different types of CHWs who played specific roles in immunisation programming. These cadres were created to distribute the heavy workload, assign specific roles and responsibilities to specialised staff and improve overall coordination and delivery of services. In Nepal, female community health volunteers (FCHVs) had a major role in immunisation, they created awareness on immunisation and linked the communities to the healthcare facilities. Senegal had five different cadres (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 as discussed in the next section.

The specific characteristics and detailed elaboration of each cadre of the CHWs in Nepal, Senegal and Zambia are outlined in table 3.

Roles and responsibilities

In the three countries, at least one CHW cadre existed. In Senegal and Zambia, most of CHWs performed similar roles. The lack of defined roles and localised training led to overlapping or deficient coverage of health services by the cadres in Zambia and Senegal.

In Nepal, key informants indicated that FCHVs, ‘the backbone of the health system’, received the most credit nationwide for improved immunisation coverage. With the increase of paid front-line health workers in 2010, the responsibilities of FCHVs shifted to building awareness of available health services and their benefits at different community levels, including local mothers’ groups (table 3).

FCHVs and the mothers’ group provide information regarding immunization campaigns or [the] regular immunization program. For new vaccines, it needs to [be] discussed with FCHVs and [the] mothers’ group—unless there is support and involvement in the program, it will not be successful because they are the one who build awareness and give knowledge and information to the people in the grass root level. (Ministry official, National level, Nepal)

In Senegal, relais and bajenu gox conduct more targeted vaccine outreach although the five cadres of CHWs serve complementary roles in delivering front-line health services (table 3). KIIs and the literature identified the relais and the bajenu gox as critical to the success of the vaccination programme, and mothers referred to them as ‘real fighters’ for the health of children. Community promotion actors were mobile, focusing on visiting communities to promote awareness of and create demand for disease prevention and health promotion activities, including vaccinations. Community members lauded the mobilisation and the motivation these actors inspired which contributed to the improvement of vaccination programming.

The involvement of community actors helps them a lot because the community actors live with the populations and know the families. Today, even after the counting, they cannot determine the house of someone or they are given the wrong telephone number. But with the involvement of community actors, they go into the neighborhoods to bring back the children. (Community health worker, community level, Senegal)

In Zambia, key informants discussed the NHCs extensively. NHCs are community-appointed volunteers whose primary role is to coordinate and manage other CHWs on behalf of health facility staff, including CHW recruitment, training and attrition. NHCs also ensure that CHWs accurately report monthly activities and represent both CHWs and community members in annual action planning. NHCs’ responsibilities have increased in the last two decades to accommodate the increasing number of CHW roles across multiple health sectors, bridge the gap in human resources and institutionalise the link between communities and the health system. Many individuals who hold NHCs role also hold another CHW position so as to receive training and other incentives through disease-specific initiatives.

A long time ago, as I said, we [community members] used to come in numbers here at the [health] center. It was difficult because we [the community] did not have enough [health facility] staff, so that’s how this [the NHC] program started. And they [NHCs] started talking to people so that we [NHCs] help each other because members of staff were few. We [NHCs] are grateful they trained us, and we are working. (NHC member, community level, Zambia)

The NHCs in Zambia were involved in action planning, identifying annual priorities, setting objectives, selecting strategies, determining indicators to monitor and evaluate activities, and estimating required activity resources and budget. Through their involvement, the NHCs indicated ownership over these responsibilities, which were formalised in the Reaching Every District (RED) programme manual.

Recognition

In all three countries, CHWs stated that recognition for their contributions and their status in the community were motivating factors. Communities, districts and regions recognised the efforts and successes of CHWs through ceremonies, certificates and media recognition. Community selection showed recognition and respect for the individual chosen to be a CHW. Particularly for women, CHWs gained stature through imparting valued knowledge, supporting caregivers and contributing to positive health outcomes.

Our motivation is we have respect through this work. Everyone praises our work. They praise our contribution towards work for pregnant women, children and delivery of pregnant women. (FCHV, Nepal)

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 FID Programme in a bottom-up approach, and this motivated community workers and volunteers, and facilitated community buy-in to immunisation. Children who are fully vaccinated receive an official vaccination card with complete information on vaccines received from their health post for documentation. Increased public awareness and FCHV activities support the success of the Full Immunisation Programme (FIP)—which promoted urgency and action among all key players, including caregivers, religious and community leaders, and teachers.

We are all working together so that the children won’t miss vaccines. We can assure you that every child in our area have got vaccines. We celebrated the immunization month at [location] last time. (FCHV, Nepal)

In Nepal and Senegal, CHWs expressed their motivation from the satisfaction they derived from belonging to their communities. CHWs highly respected their communities, and they served voluntarily because of the mutual respect between community and CHW. Seeing children in their communities protected from diseases and growing up healthy was additional motivation. FCHVs had pride and expressed happiness if all the children within their catchment areas were fully vaccinated. A FCHV in Nepal stated that ‘they worked for the good of the community.’

Incentives

In all countries, incentives (table 1) were crucial to engage and motivate CHW volunteers. Though inconsistently distributed, tangible extrinsic resources—including money, food, bicycles, uniforms, stationary, childcare and harvesting assistance—motivated CHWs and could reduce any intrahousehold tensions caused by absences due to the programme. When CHWs areas of jurisdiction reported low vaccination coverage, especially in comparison to other districts or regions, their motivation to improve outcomes increased.

We do recognize them [FCHVs]. We do a public audit and take decisions on whom we should give credit; that is recognized by the community and system so that they become more motivated. (Regional Director, Nepal)

However, even with efforts to recognise CHW contributions, CHWs in all countries felt underappreciated by the national government. They expressed that the appreciation they received was more evident in the community than by the government. In all countries, CHWs felt they lacked commensurate compensation for their labour; they were required to commit to being a volunteer. Retention suffered because in some instances, CHWs were forbidden to engage in income-generating activities, and compensation was often inconsistent. CHWs families often expected them to complete household labour even though they were engaged in volunteer responsibilities. Community health volunteers often supported and contributed to the work of paid CHWs and head nurses, resulting in additional workloads without appropriate compensation. Additionally, countries’ projections for labour were unmet, leading to heavy responsibilities for CHWs.

Capacity building

CHW’s knowledge increased through training and supportive supervision; in many cases, the opportunity to learn new skills and knowledge promoted self-value and enhanced their capacity to support the communities in the three countries. CHWs received formalised training through national health programmes, Non-governmnetal organizations (NGOs) and multilateral partners; however, the length, breadth and depth of training differed by country and trainer (table 3). Key informants valued NGO and multilateral training, which provided financial incentives. Some FCHVs and bajenu gox reported the benefits of CHW literacy promoting groups. In all countries, CHW used their community knowledge through identification of community needs around immunisation, which informed decision-making, and ultimately contributed to planning at higher levels. CHWs had frequent interactions with the local population, as they resided in those communities. This facilitated their deeper understanding of the community’s needs, which they escalated during planning meetings. The frequent interactions between CHWs and community members through community dialogues and education, and encouragement of knowledge sharing between the community members themselves enhanced community empowerment, enabling development and maintenance of social norms related to vaccination.

Supervision of CHWs occurred in all countries. Supportive supervision increased CHWs self-confidence through cross-learning and skills sharing facilitated teamwork, and enhanced relationships with healthcare workers. In Senegal, bajenu gox received supportive supervision while working in communities. Their supervisors recorded field visit results on a standardised checklist and sent supervision reports to the district medical offices for review. However, supervision in the field may have been rare due to a lack of human resources. In Zambia, the NHCs had a supervisory position over CHW reporting, and played an essential role in data collection and evidence-based decision-making. Prior to taking up their roles, NHCs received training, which enhanced their capacity to perform their duties. NHCs were motivated by these responsibilities because they elevated the NHC’s position and described the emphasis on community-driven strategies to combat health challenges. Health facility staff and supervisors from the districts included NHCs in meetings and trainings, which provided encouragement. According to national policy, by encouraging the possession and responsibility of data, the front-line workers reviewed their performance against their stated goal, identified gaps and discussed ways to improve vaccination coverage.

There is the NHC that spearheads all community activities because all the CBVs, all community volunteers, they report through the NHC. (District Nursing Officer, Zambia)

Although CHWs in all countries desired consistent and increased opportunities for training; these differed significantly depending on the location and human, financial, and material resources.

Empathy and compassion

CHWs expressed being motivated by their sense of empathy and compassion for their communities in all three countries. CHWs understood and shared the feelings of their fellow community members and showed concern for their suffering and misfortune. This motivated CHWs to perform their roles well since they felt invested in the health of the community at large in addition to children’s health. CHWs understood the lived experiences of the community members and had compassion for the potential morbidity and mortality of children when not immunised against vaccine-preventable diseases. This increased their effort to focus on improving the health and well-being of children in their communities.

Vaccine prevents from many diseases that is also why people bring their children for vaccination. There were more Pneumonia cases and diarrheal diseases before but nowadays there are very less children who suffer from Pneumonia and Diarrhea. If we hear that some children have suffered from diseases, then we feel very worried. We also feel responsible towards those children. (FCHV, Nepal)

Community engagement and knowledge sharing

Communities in all three countries were involved in decision making, planning, design, governance and delivery of services. Information and skills were shared between individuals or groups, and this included frequent interaction, and social relationships between CHWs, communities and health workers. CHWs were involved in providing health education at facilities, thus creating awareness about immunisation.

FCHV sisters also help us and teach us about [health]. They also teach and train us to get vaccination for the children… We trust [the information] and it is for our children. It is better not to suffer from any diseases. First, we need to have proper information about it and only then trust it. (Female Community Health Volunteer, Nepal)

In Nepal, FCHVs were required to work in the communities they resided in; CHWs reported that this generated trust and promoted 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, misinformation and cultural norms. FCHVs educated community members in mothers’ health groups, ensured the group’s integration into their assigned communities to share health information with community members. In women’s savings groups (groups of women who come together to save, and lend, money to members), FCHVs emphasised the link between children’s health and future educational and occupational opportunities. FCHVs also approached caregivers individually, discussing potential barriers to immunisation, addressing specific information caregivers lacked and encouraging immunisation access. As FCHVs were embedded in the communities where they conducted outreach, their messaging incorporated differences in religion, tribe or caste, ethnicity and language.

I: How much do community members trust the sources of Vaccination information? //P4: Yes, they have trust. //All at a time: yes, we believe on them. //P5: Because they will also learn some information from here and provides us other information. // P4: They will learn from here and teach us. (Mothers, Nepal)

In Senegal, 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. To address the lack of necessary human resources for community health outreach and support in Senegal, the MoH, under a USAID-funded community health plan, instituted the bajenu gox (godmothers) programme in 2009. The bajenu gox was trusted older women—‘proven female leaders’—living in the community who capitalised on their age and social role to support pregnant women and their families in prenatal to postnatal health, including immunisations (table 3). Bajenu gox duties were specifically targeted at building relationships of trust with community members. Many mothers specifically praised the bajenu gox for taking the time to explain diseases that vaccinations targeted, when vaccinations were happening, follow-up and individualised planning.

Special mention to our bajenu gox. We are all women, and we see the support they give us; they are our mothers and at the same time our bajenu gox. They leave all their activities to follow us and our children…each time there is a vaccination to be given; they identify the people concerned and accompany them to be vaccinated. Because vaccination is very important, before we said that without it, we could catch all kinds of diseases such as measles and others, but now we have more vaccines and thank God we have fewer diseases, and all our children are protected. (Mothers, Senegal)

Trust between the health workers and the bajenu gox was enhanced through supportive supervision. NGO employees, community development agents and head nurses were intended to provide supportive supervision for bajenu gox while they were working in communities, record field visit results on a standardised checklist, and send supervision reports to the district medical offices for review. This allowed for confidence and trust with service delivery among bajenu gox, the communities and healthcare workers.

In Zambia, NHCs played a prominent role in community sensitisation, outreach and vaccine education in most of our research communities in Zambia. NHCs 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. For example, if the barrier to access were due to a parent’s competing priorities, the NHC member would escort the child to the outreach event.

There is some time on the radio, and they call the NHC to come and talk about health issues. They encourage, especially in the village. They announce that next week, 'do not delay the children to come for vaccinations.' Yes, because of the community radio, they let anyone talk. Yes, especially the NHC, they talk a lot on encouraging other vaccines. (Head Woman, Zambia)

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