Direct Consulting & Logistics Evaluating SMS messaging for immunization demand generation in Nigeria: Immunization Reminder & Information SMS System (IRISS) Project Brief January 2021 Reasons children are not fully vaccinated in Northwest Nigeria, NICS 2016/2017 Despite some progress made in the Nigerian routine 14% thought 15% had no child was fully faith in immunization (RI) program in recent times, about three million immunised immunisation children remain unvaccinated. According to NDHS 2018, 50% 37%A 32% of children aged 12-23 months received all three pentavalent Lack of 13% reported Mistrust or 10% reported awareness immunisation fears caretaker too vaccines nationally. Coverage is highly variable across the site was too far busy country with the northwest and northeast zones having the 22% Lack17% of time or worst performance. In Kebbi State Northwest Nigeria, only Service delivery other family issues issues 11% of children received 2 Penta3, and a mere 6% were fully Note: Respondents could identify more than one reason for incomplete immunisaton. vaccinated by age two. Map of Kebbi State showing the intervention and control LGAs Augie Immunization investments by the government and partners in Argungu Arewa Dandi Gwandu the last decade have primarily addressed supply-side Bimin Kebbi Kalgo Aleiro problems. Still, the demand for vaccines remains low due to Bunza Intervention LGAs Jega Control LGAs 3,4 Suru a lack of information and knowledge about the RI Dandi Maiyama Koko Bease program. Fakai Zuru Shange Wasagu/Danko Bagudo Sakaba Between January 2018 and August 2020, the International Yauri Vaccine Access Centre (IVAC) in collaboration with the Direct Consulting and Logistics (DCL) and the Kebbi State Primary Ngaski Health Care Development Agency (KSPHCDA) implemented an SMS reminder intervention to inform and nudge community members and caregivers about vaccination. This gatekeepers (District Heads, Village Heads, Mai- approach has proven successful at improving immunization ungwas, Imams) to pass on to their community and uptake in multiple settings. The project was designed as a congregation. two-arm cluster randomized controlled trial to assess the SMS 3. As individualized/personalized reminders to reminder's impact on vaccine coverage. Fourteen (14) caregivers and other individuals who opted-in to receive intervention local government areas (LGAs) received the SMS messages on the child's vaccination schedule. intervention, and seven (7) control LGAs did not receive the SMS intervention. The Approaches, Strategies, and Challenges The project team conducted the following activities for the The Intervention successful implementation of the IRISS project in Kebbi State. IRISS (Tunatar da ni, meaning "Remind me" in Hausa) used SMS to inform and educate the community and 1. Conducted a formative study to understand the caregivers/parents about the importance of immunization; context and inform message development and and remind them of their child's immunization schedules, design of the IRISS intervention: FGDs and KIIs were including health facility vaccination schedules in their locality. conducted among program managers, community The project aimed to raise parental demand for vaccination members, RI providers, KSPHCDA leadership, and and reduce the proportion of children left out (un-vaccinated) partners in Aleiro, Argungu, Fakai, and Shanga LGAs in and drop out of the RI program (under-vaccinated). October 2018. We collected data on social norms about vaccinations, barriers to immunization uptake, mobile IRISS delivered immunization information to parents, phone use, SMS message testing, and willingness to caregivers, and the public in three ways: accept IRISS. 11 FGDs, 12 IDIs, and 13 KIIs were 1. As general broadcasts to the public with informative conducted. The key results were as follows. messages about immunization in general and a prompt to a. We found positive perceptions and beliefs about opt-in to IRISS e-registry for more information. the importance of vaccination for child health 2. As targeted broadcasts with information on the benefits among participants interviewed, even among those of immunization and immunization clinic days for the without children. nearest health centre to Leads (individuals that b. There was a high level of trust in health workers. responded to general broadcast) and community Traditional and religious leaders were strong 1 influencers for promoting vaccinations. 2 World Health Organization. 2019. Progress and Challenges with Achieving Universal Immunization Coverage. Available at: https://www.who.int/immunization/monitoring_surveillance/who-immuniz.pdf? (accessed October 12, 2020) 3 National Population Commission (NPC) [Nigeria] and ICF. 2019. Nigeria Demographic and Health Survey 2018. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF. 4 International Vaccine Access Center. 2017. Nigeria Brief Template North West Zone. Available at: https://www.jhsph.edu/ivac/wp-content/uploads/2018/04/Nigeria-NICS-Brief-North-West-Zone.pdf (accessed October 12, 2020) National Primary Healthcare Development Agency and National Bureau of Statistics. Nigeria, National Immunization Coverage Survey 2016/17, Final Report. Abuja, Nigeria: National Primary Healthcare Development Agency and National Bureau of Statistics. 1 c. Pockets of misconception about vaccine safety, Focal Persons, and community leaders (Mai-unguwas), beliefs that vaccines are associated with fertility for ease of use and registration accuracy. Following the reduction, and personal and religious beliefs remain pre-test, a new simplified opt-in format for caregivers, among some community members leading to gatekeepers, and health workers was deployed in May vaccine hesitancy. 2019. Also, proxy registration opt-in format was d. The most common barriers to vaccine uptake across implemented to account for low phone ownership all LGAs were a lack of knowledge on vaccines' IRISS opt-in forCaregivers mats for carGatekeepersegivers, gatekeepers, and health workers Health workers benefits and adverse effects following vaccination, Direct registration: Village heads: RI providers: Firstname lastname, DOB, Vhead, firstname lastname, Provider, firstname h u s b a n d d i s a p p r o v a l , a n d Hfname, LGA name Hfname, LGA name lastname, Hfname, Proxy registration: Mai-ungwas: designation, LGA negligence/forgetfulness. name Proxy, firstname lastname, Mai-ungwa, firstname e. Low mobile phone ownership was observed, DOB, Hfname LGA name, lastname, Hfname LGA phone number name especially among rural hard to reach areas, and Imams: most phone owners were husbands. Literacy levels Imam, firstname lastname, Hfname LGA name and the ability to read text messages were low, but most participants indicated access to someone who could read the text messages for them. 4. Sensitized over 7,000 stakeholders in the 14 f. IRISS intervention was perceived as timely and intervention LGAs: Due to overlaps between the useful for educating and reminding parents on Community Engagement Strategy (CES) and the IRISS immunization program objectives concerning registering newborns g. The IRISS intervention was culturally and religiously for immunization service delivery, we integrated the acceptable with strong support from traditional and sensitization of both programs. At the National religious leaders, who were receptive to receiving Emergency Routine Immunization Coordinating Centre SMS messages and disseminating the same to their (NERICC) request, we supported CES activities in Kebbi communities, despite concerns about low phone State. We obtained phone numbers at each level of ownership. government to have a community-level subscription for 2. Developed messages for dissemination: We tested a targeted broadcast. Between January and May 2019, total of 33 messages covering reminder, educational, we successfully sensitized over 7,000 stakeholders motivational, informative, and normative contents in 2 on IRISS and CES in the 14 intervention LGAs LGAs among community leaders and parents of children including the traditional leaders to obtain their buy-in under-five in October 2018. Each message was tested for for the project. Additionally, information, education, clarity, comprehensibility, relevance, cultural and communication (IEC) materials (e.g. one-pager, appropriateness, and ability to motivate action. All calendar, and other training materials) depicting the messages were generally found to be relevant, step-by-step process of registering for SMS reminders motivating, and culturally acceptable. were developed and used during the stakeholder 3. Established the IRISS application for message sensitization training. These IEC materials were pre- dissemination: Working with an in-country developer, tested during FGD before dissemination. Participants Interra Networks, the IRISS application was developed in kept the materials for reference. Q4 2018 after testing and refinement with insights from List of Stakeholders sensitized in the 14 intervention LGAs and the IEC materials usedCategory Stakeholder No. sensitized (%) IEC materials used Emirs 4 (100%) IRISS One-pager the formative study described above. The system was Emir Focal Persons 4 (100%) IRISS One-pager Traditional Leadership District Heads (DHs) 80 (100%) IRISS One-pager deployed in May 2019 to send the targeted and Village Heads (VHs) 742 (100%) IRISS calendar individualized broadcast to registered contacts. The Mai-unguwas 5707 (100%) IRISS calendar SERICC members 24 (100%) IRISS One-pager NPHCDA