Evaluating SMS Messaging for Immunization Demand Generation in Nigeria

Background and rationale:

Vaccines are one of the most effective and cost-effective interventions available to public health today. But the benefits of vaccines are not getting to all children, particularly in Nigeria. The 2016 National Immunization Coverage Survey (NICS) reports that only 33% of children aged 12-23 months received the third dose of the pentavalent vaccine nationally. In addition, as much as 40% of children had zero dose of vaccines from the routine immunization (RI) program by the age of two years, having been left out of the "service grid". Even among children that have access, retention and utilization is poor; as much as 31% of children who received their first pentavalent vaccine dose, drop out. They do not return to complete the third dose in the series.

In the 2016 NICS, barriers related to lack of knowledge were the most frequently cited barriers by parents of under-vaccinated children. In Nigeria, RI is delivered through fixed sessions at health clinics and outreach sessions in the communities. To complete the RI schedule, caregivers are required to proactively take their infants to the service sites a total of 5 times in the child's first year of life. As much as 42% of parents cited knowledge-deficits such as, not appreciating the importance of vaccines, not knowing the schedule or not recognizing the need to seek out vaccination services as reasons for not vaccinating their children. The complacency to seek RI services may be linked to some parent's erroneous belief that the door-to-door vaccination of their children during polio eradication campaigns (with oral polio vaccine) provides their children with all the vaccines they need. Low confidence, inconvenient clinic schedules and location may also underline the poor demand for RI services.

The health belief model and theory of planned behavior provides an organizing framework to articulate how knowledge, perceptions, subjective norms, self-efficacy and cues to action influence behavioral intention and action. Based on this theory, the team identified that Short Messaging System (SMS) messages and reminders could serve the three-fold purpose of providing information, shaping subjective norms and cueing caregivers to action.

Study investigators hypothesize that providing community leaders with positive and actionable messages on immunization services will improve their understanding of the value of vaccines and provide them facts to drive discussions about vaccination in the community. These discussions about vaccination will result in a common understanding of its importance, increase support for it and build greater positive norms about it in the community. Furthermore, if vaccination schedules for local clinics are sent to the community leaders through SMS, and they, in turn, ask their town announcers to announce the session times in the community, this may serve as cues to action for parents of vaccine age children. In the same vein, providing targeted reminders to parents about their child's vaccination due date and the schedule of their health center will motivate their timely action to seek vaccination services for their children.