2 Background

The initial outbreak of COVID-19 was reported in December 2019 in China [1], which propelled into a multifaceted health challenge within three months of its emergence across the globe [2], subsequently resulting in its declaration as a pandemic in March 2020 by the World Health Organization [3, 4]. Aside from being an unknown threat to the global populace at the onset, it equally orchestrated the disruption of several existing public health interventions [5, 6], especially in low and middle-income countries (LMICs) [7, 8]

According to Ihekwazu [9], these challenges resulted from the limited convergence of vertical disease program resources to strengthen the entire health system in LMICs. One of many health programs affected by the COVID-19 menace was the immunization services offered to children 0–59 months, through Routine Immunization (RI) [10, 11]. RI is considered the hub of healthcare services for children, and a preventable channel for reducing under-five mortality rates, by preventing them from various infectious diseases [12,13,14]. The World Health Organization [15] and Adamu et al., [16] predicted that the halting of RI services increased the susceptibility of about 80 million children across 68 countries to various vaccine-preventable diseases including diphtheria, measles, and polio, thereby endangering the lives of these children.

Following the emergence of COVID-19 vaccines, scholars such as Adamu et al., [16] contended the importance of exploring the integration of COVID-19 vaccination into routine immunization. Subsequently, the WHO Strategic Advisory Group Experts (SAGE) on immunization plausibly advised countries to leverage the COVID-19 vaccination rollout as a transformative opportunity to establish a resilient immunization system, through an integrated immunization strategy, resulting in strengthened primary healthcare services [17, 18].

The National Primary Healthcare Development Agency (NPHCDA) defined the eligible population for the COVID-19 vaccines in Nigeria to include adults over 18 years of age [19], but in rare cases of students traveling outside the country to school, children who are 16 years and above were allowed to be vaccinated [20]. This was adopted across all states in the country. On the other hand, while RI is offered to children from 0 to 59 months based on the National RI guidelines [21], many of the children who received RI during the intervention on integration in Ekiti state, were less than 2 years of age. The children are expected to have received about 22 antigens including yellow fever, Hepatitis B, measles 1 and 2, and polio vaccines, to be considered fully immunized [22, 23]

Mirza et al. [24] in a study across 11 African countries (including Nigeria), reported that COVID-19 vaccines facilitated a gateway for high-priority populations (like the elderly, health workers, and people living with comorbidities) outside of the traditional system for children and women of reproductive age, providing opportunities for integrating other health interventions. This also fostered multi-sectoral collaboration between ministries and private sectors. Lava et al. [25] also found that aside from the increased COVID-19 vaccination coverage, integrating the COVID-19 vaccine services into primary healthcare improved individuals’ access to healthcare in the Philippines. However, poor strategic planning, an overburdened health workforce, and the unavailability of a supply chain logistics management system posed threats to this integration in some African countries [24, 26].

Thus, this approach of integrating into routine immunization programs was adopted across all states in Nigeria. The Ekiti State Primary Healthcare Development Agency (ESPHCDA through the National Primary Healthcare Development Agency (NPHCDA), and the collaborative partnerships with local and international implementing partners adopted an integrated immunization strategy premised on a fixed team and mobile team approaches. The fixed team operates from the health facilities and is usually the immunization team in the health facilities. On the other hand, the mobile team is often more in number and tasked with visiting villages and communities. Against this backdrop, this study assessed the enablers and barriers of integrating COVID-19 vaccination into the routine immunization programme in Ekiti state, Nigeria.

2.1 Research methods

This study adopted a qualitative research approach to obtain information from 40 participants selected purposively across the primary healthcare facilities, Local Government Area (LGA), and state levels. A three-tier approach was used to select the LGAs. At the same time, In-depth interviews were conducted to elicit relevant information on the assessment of enablers and barriers to integrating COVID-19 vaccination into routine immunization through an interview guide.

2.2 Study settings

The study was conducted in Ekiti State, southwest Nigeria. Bordered by Kwara, Kogi, Ondo, and Osun states, Ekiti was founded from a portion of Ondo State in 1996 and has Ado-Ekiti as its capital. The state is named after the Ekiti people, a Yoruba subgroup that makes up the bulk of the state's population. The study participants are health workers at the facility, local government, and the state primary healthcare levels. These categories of health workers are all in the immunization unit of the primary health care agency. The health workers at the facility level include the RI focal Person and a recorder. Health workers at the LGA level include the Local Immunization Officer (LIO), the LGA Monitoring and Evaluation (M&E), and the Local Health Education Officer (LHEO). At the state level, participants include the State Immunization Officer (SIO), the State M&E, and the State Health Education Officer (SHEO).

2.3 Study participants and selection

This study utilized a three-tier purposive sampling to reach the target audience. In the first stage, the study purposively selected 9 LGAs across the three senatorial districts in the state. In the second stage, apex primary healthcare facilities were selected in each of the selected 9 LGAs. In the third stage, participants were identified at the Primary Health Care (PHC) facilities, and the LGA levels in the state. Two health facility officials (the facility Recorder and the RI Focal Person) and two health officials at the LGA level (LIO and LHEO) were purposively selected because of their depth of knowledge and experience on the subject matter. The study also purposively identified state-level health officials (SIO, M&E, SHEO) as custodians and implementers of the integration approach. A total of 40 interviews were conducted among the study participants (Please see Table 1).

Table 1 Participants selection in the study location
Full size table

2.4 Data collection

A semi-structured in-depth interview guide was developed for participants at the facility, LGA, and state levels, to obtain the data needed for the study. The interview guide was structured using the WHO Health System Building Blocks Framework [27] in line with the objective of this study. Verbal consent was obtained from the respondents before all the interviews were conducted, by asking participants to give their go-ahead before the commencement of the interviews. Additionally, participants were informed that their participation was voluntary and that they had the right to withdraw at any point. All interviews were conducted in English Language to facilitate easy communication. The interviews lasted under 60 min, were recorded, and stored on an audio smart device.

2.5 Data analysis

The recorded interviews and discussions were transcribed in Word format by professional transcribers. The transcripts were validated by the research team and subsequently uploaded into Dedoose software. A thematic analysis using the WHO Health System Building Blocks Framework (27), combining deductive and inductive approaches, was adopted for analysis.

A codebook was then developed and uploaded to the software to guide the analysis of the transcripts. A spreadsheet of the excerpts from the codes was exported as analysis output from the software depicting the quotes from the transcripts of each participant that fit within the identified themes. The excerpts were reviewed to make connections between and within participants to seek explanations for the patterns of the themes.

3 Results

3.1 Socio-demographic characteristics of participants

A total of 40 healthcare workers across Ekiti state were selected to participate in this study. The majority (87%) of the participants were females. Nearly 2 out of every 5 (38%) study participants had post-secondary certificates from nursing school and community health institutions, while 52% were first-degree (BSc) holders. The mean age of the study participants is 46.4 years. (Please see Table 2).

Table 2 Socio-demographics characteristics of participants
Full size table

3.2 Participants’ knowledge of COVID-19 vaccination into routine immunization integrated approach

3.2.1 Health workers’ description of integration

In exploring the integration of COVID-19 vaccination into routine immunization (RI) within health facilities in Ekiti, it was highly pivotal that we assess the participants’ understanding of integrating COVID-19 vaccination into RI services in the state, particularly at the health facility level. Therefore, the study participants were asked to express their interpretation of integrating COVID-19 into RI services in the state. All the participants believed and mentioned that it means combining two services organized to achieve similar goals. The following are feedback from the study participants:

“Thank you. Integration is the joining together of small bodies to become a whole. The integration of COVID-19 into RI is how we administer COVID-19 vaccination and routine immunization together.” (IDI/Routine Immunization Focal Person/Ikole Ekiti LGA).

“Well, with the word integration, the two services and other services were provided together. And with the COVID-19 and the RI vaccination, it's increasing the coverage for RI and the COVID vaccination in Ekiti” (IDI/LGA Immunization Officer/IKERE LGA/).

“One of the thematic areas was the integration part, which was integrating COVID-19 into the routine immunization services at the facility level, and how it played out was that it played out in two parts, we had the outreach team and the fixed team. Outreach teams were charged with the duty of visiting various settlements, especially hard-to-reach environments, and tracking those who have been defaulting on taking their first dose, … while the facility teams were charged with the duty of vaccinating those who come into the facility to do something or get treatment for one ailment or the other”. (IDI/Assistant Technical Adviser/Ekiti State).

3.2.2 Perceived benefits of the integration

Findings from the study revealed that participants expressed their opinions on the benefit of the integrated approach adopted for optimizing COVID-19 vaccination into routine immunization. Participants agreed that the benefits of the adopted strategy improved vaccination coverage for both exercises. The following excerpts provide more context:

“The benefit of integration has improved the uptake of the COVID-19 vaccine such that it has increased women’s uptake of the vaccine, and it has helped in opening the minds of our patients to the importance of vaccination”. (IDI/Recorder/Ikere LGA).

“The benefits of the program include helping us to reach the unreached and through that, it also assisted us to have more coverage in all our antigens. Before the program in these areas, we have been experiencing dropouts … But during that program, we were able to cover those areas, to reach all those children and we were able to vaccinate them”. (IDI/LGA Immunization Officer/Ifelodun LGA).

“The benefit is that it increased the coverage and allowed the defaulter to be tracked at the health facility level. During the integration, we used to track defaulters. We also monitored and completed the doses received during the campaign and conducted house-to-house visitations”. (IDI/M&E/ESPHCDA).

3.2.3 Integration as a facilitator of improved coverage

Participants said the adopted integration strategy influenced the increased coverage of COVID-19 and routine immunization through leveraging opportunities associated with the integration. In other words, the availability of a child for immunization ensures the availability of the caregiver/mother for vaccination, depending on the caregiver’s vaccination status, and vice-versa (that is if the adult has an eligible child). In essence, participants stated that:

“The way it has helped is how it makes people come out of their houses because, for several people, it is burdensome for them to bring their children for immunization at the facility. So, it has helped our immunization work increase and that of COVID-19”. (IDI/Recorder/Emure LGA).

“In Emure local government, the integration of COVID-19 with RI has helped in coverage because since it has been integrated, even when a mother brings her child to the facility, she has access to the COVID-19 vaccine. So, they have access to the vaccine when they need It”. (IDI/LHEO/Emure LGA).

“An illustration that we want to give towards improved coverage is that there are people who find it difficult to come into the facility probably because they have one challenge or another thinking they will pay before they can get vaccinated and some because they are not even interested in COVID-19 vaccination but because there are some other vaccines that their child have to take and, in the process, they are already being informed. They will then explain to the caregiver and give the child and caregiver their vaccines” (IDI/Assistant Technical Adviser/Ekiti State).

3.3 Enablers of integrating COVID-19 into routine immunization

To effectively assess the drivers of integrating COVID-19 vaccination into routine immunization, we employed the WHO Health System Building Blocks Framework, utilizing the six components, to easily disaggregate the immunization structure in the state.

3.4 Service delivery

To ensure a good understanding of how service delivery has aided the integration of COVID-19 vaccination into routine immunization, the service delivery component was further divided into sub-themes that comprehensively address the provision of health services in the immunization unit of primary healthcare.

3.4.1 (i) Demand Generation and Social Mobilization

The study participants (health workers) explained that their demand generation activities are dichotomized into two major areas to ensure reaching the people in the rural communities. The following are the steps adopted by the team when engaging community stakeholders.

3.4.1.1 a.) Stakeholders Engagement.

Responses from the study revealed that the team commenced their activities with community entry by establishing adequate connections with stakeholders at the community levels. They obtain the buy-in of all community leaders to facilitate easy access to community members. Participants enunciated that:

“First of all, we started with advocacy, we paid advocacy visits to influential people in Ekiti state, and we involved all the chairmen in Ekiti state and all the traditional leaders, religious leaders, and civil society organizations like Rotary club in Ekiti state. We normally hold meetings with them to sensitize them in their palace. … we leveraged their monthly meeting and Iyaloja’s (Women Market leaders)”. (IDI/SHE/EKITI).

“The demand and awareness generation campaign started with traditional leaders because the mode of entry into any community is always important. After that, we held town hall meetings, age group meetings, and compound meetings”. (IDI/LHE/IFELODUN LGA).

3.4.1.2 b.) Awareness Creation/Community Sensitization

The health workers at the state and LGA levels took the next step of creating awareness and sensitizing community members on the importance of receiving COVID-19 vaccination into routine immunization. They aimed to ensure that residents of the communities willingly accept, to receive either the routine immunization for their children or the COVID-19 vaccination for themselves (especially if they have not accepted their first dose, or/and have missed subsequent doses). Therefore, participants expressed that:

“We did radio jingles and media chats. We did live workshop programs on both TV and radio stations. Apart from this, we have our platforms where we normally share all the information. If we produce a jingle, we share it on this platform for everybody and we also encourage all our leaders, religious leaders, and the Iyalojas that when we throw it to their platform, they will help us to also send it to all the platforms they belong” (IDI/State Health Education Officer/Ekiti State).

“During the antenatal clinic, any clinic whatsoever, or any community gathering, we sensitize people about it, that now you can bring your child to the facility and receive your COVID-19 vaccination. It helped and supported the system”. (IDI/LHE/IDO LGA).

“We announced to people through radio jingles, and phone calls telling them that vaccination is now available at the center and the mobilizer also goes around to inform people”. (IDI/RECORDER/IFELODUN LGA)

3.4.2 (ii) Health education

Participants expressed that, residents of the state across various communities, particularly those who visited the health facilities, such as the caregivers, were significantly educated on COVID-19 vaccination (including the significance, and potency, amongst others). The participants added that the residents were not only educated but were also provided with IEC materials, as this is evident in their statement:

“We had various IEC materials talking about the COVID-19 pandemic, how it can be contracted, and even talking about the vaccines, the potency, and the safety of the vaccines”. (IDI/State Immunization Officer/Ekiti State)

“Yes, like I have rightly said during our clinic sessions, we leverage these sessions to speak about the integration, then during any community meetings we speak about it, especially about the COVID-19 vaccination, and the integration of the two. Also, during one-on-one discussions, we discuss it with the people”. (IDI/LGA Health Education Officer/Ido LGA).

“In our facility, we carry out health education, we explain the benefits of immunization and how to take precautions such as no shaking of hands, and using of a nose mask, and we tell them about the things they should do and not engage in that can have a consequence on their health” (IDI/Recorder/Ijero LGA).

3.4.3 (iii) Vaccine accessibility

The healthcare workers interviewed for the study emphasized that the eligible populations had access to vaccines throughout the program implementation. Ease of access was ensured by operating fixed-post and mobile outreach teams. The fixed post teams are located in the facility where community residents could visit to get immunized or vaccinated. On the other hand, the outreach sessions involve healthcare workers moving around the communities where the facilities are situated to take immunizations and COVID-19 vaccinations to the communal residents’ doorsteps.

“The people around had access to the vaccine because we did fix post and outreach (sessions) in which case we went to their doorsteps to give them the vaccine. Thanks to the effort of the program organizers who funded the outreach. We were able to reach several people at their workplace, we met them at their various villages and settlements, where we administered the vaccine”. (IDI/LGA Health Education Officer/Ifelodun LGA).

“We took it to them, then some came, and we operated both outreach and fixed post (sessions)”. (IDI/Routine Immunization Focal Person/Emure LGA)

3.5 Health workforce

Subsequently, the study assessed the health workforce component of the health system to understand its contribution to strengthening the immunization health system of the Ekiti State Primary Healthcare Board. Additionally, this component sheds light on the health workforce’s contribution to the optimization of integrating COVID-19 vaccination into routine immunization. To this end, two key areas were discussed: Training the health workers, and temporary engagement of ad-hoc staff.

3.5.1 (i) Training

While the NPHCDA believed in the recommended integrated strategy for optimization of COVID-19 vaccination into routine immunization, this had not been implemented in any part of the country. Therefore, the intervention in Ekiti state was considered a “Proof of concept” for the strategy of integrating into RI, wherein the existing immunization guideline was adapted to include two vaccinators and two recorders, The study participants were able to call out that before the commencement of the integration strategy for the optimization of COVID-19 vaccination into routine immunization, health workers involved in the support were trained across all levels.

“We were trained on the integration of COVID-19 into RI. We went for training on how to do everything (hands-on) such that as we’re administering COVID-19 vaccines, we’re doing routine immunization. So, we were trained”. (IDI/Routine Immunization Focal Person/Ikole Ekiti LGA).

“There was training, and there was also retraining as part of the program's success story. Health workers were trained before the commencement of the program. We were all trained at different levels, and they trained us equally. We also trained the mobilizers, so that the program could be sustained. So, they also have adequate knowledge of COVID–19 and RI services”. (IDI/LGA Immunization Officer/Ijero LGA).

“Yes, we had training. We went to National for training, after which we came down to the state to cascade the training. Afterward, we developed our micro plan that integrates all those services, and the training was conducted effectively at the state level and down to the local government level”. (IDI/M&E/ESPHCDA).

3.5.2 (ii) Ad-hoc staff recruitment

In the interview conducted, the study participants expressed that the shortage of manpower influenced the need for additional recruitment of ad-hoc staff to strengthen the workforce for the optimization of COVID-19 vaccination into routine immunization in Ekiti state. The engaged ad-hoc staff are usually residents or/and members of the communities who possess important skills in other areas, particularly technological skills, where the services were needed to optimize COVID-19 vaccination into routine immunization.

“Yes, there was recruitment, because not all those that supported outreach were health workers. At the facility, which is the fixed team, we ensured that, for the sake of the integration, only the RI officer and the recorder were allowed to work as part of the team for the fixed team. While for the outreach team, to complete the number of personnel needed for the team, we other members of the team aside from the vaccinators one of whom led the team” (IDI/Assistant Technical Adviser/Ekiti State).

“Yes, because presently in Ekiti State, we are all aware of staff shortage. As a result, our staff will not be enough to cover all the communities. So, we had to recruit some ad hoc staff, in which they were also trained along with our staff, to be able to carry out the activity”. (IDI/LGA Immunization Officer/Ifelodun LGA).

“Yes, we employed ad-hoc staff. The likes of the mobilizers and those who are conversant with the communities who know the in -and—out of the communities, people that were given to us to help us mobilize people” (IDI/Recorder/Ikere LGA).

“The likes of the mobilizers and those who are conversant with the communities who know the in and—out of the communities were available to help us mobilize people” (IDI/Recorder/Ikere LGA)

3.6 Commodities and vaccines

In discussing the measures taken to ensure the availability of commodities and vaccines for the seamless operation of the intervention geared towards the optimization of vaccination services in the state, participants emphasized that they structured their micro plan with an adequate standard, and adhered to the micro plan developed, as this aided management of commodities and vaccines across the state.

“We used what was developed in the micro plan to supply all the materials required. So, in that area, since they are given all the micro plans that are robust and cover every resource, then from that micro plan, that's where we supply. And then we ensured no area lacked all the required resources from our end. So, they give us what they have, and we compare it with the target population. Then we make available the supply through the cold store to ensure that those commodities; the syringe, the vaccine carrier, everything was provided”. (IDI/M&E/ESPHCDA).

“We have something we call bundling; it is like a package deal. When you get a vaccine dose, you get all other necessary supplies like syringes, needles, cards, and cotton wool. It ensures that everything needed for the vaccination is provided together. So, it's not only about counting the doses but also ensuring the availability of all the materials required for a smooth vaccination process”. (IDI/LGA Health Education Officer/Ido LGA).

“We had a plan that we used to provide everything that we would need for the program. There has never been a time we ran out of supplies of commodities. So, we monitor the supplies to know when they are running out. And most times it's LIO that gets it for us”. (IDI/RECORDER/GBONYIN LGA).

3.7 Health information system

Quality and reliable immunization data is the lifeline of sound and informed decision-making in healthcare interventions. A robust data reporting structure was set up to generate quality data from the integrated program. Subsequently, a trained and technologically inclined health worker was reporting at the facility level, while technologically skilled individuals, usually hired as ad-hoc staff were utilized for outreach teams, to ensure adequate electronic reporting. Their roles were to report and record data. Regular data validation and verification meetings were held at all levels of operation. Participants expressed the following:

3.7.1 (i) Data recording and reporting

“At the facility level, we have the recorder and the RIO. At the end of the month, they collate their reports. Vaccine utilization must be checked across the board to tally with the number of people that have been immunized for the month, while the RIO is reporting to the CCO and the LIO the recorder also reports to the M&E, and later the LGA level, at that LGA level the M&E, the LGA M&E, the LIO, and the CCO will now look at those data again before uploading to the DHIS but, when we also came on board we requested that they maintain the reporting structure and made some little improvements”. (IDI/Assistant Technical Adviser/Ekiti State).

“Yes, using Kobo Collect and all other platforms daily even immediately they are vaccinating, they are capturing all this data and sending it to the appropriate person, and the M&E for the LGA usually does the summary and sends it to the appropriate person”. (IDI/LGA Health Education Officer/Emure LGA).

“When the patient comes to the facility, I will take the paper record and request demographic information. Subsequently, I will enter similar information and others into my phone, and later tell the person to proceed with the vaccination. After vaccination, I will record on DHIS 2 stating if it is the first time or second time of vaccination. I will then collect all the data from both immunization and COVID-19 and record it on Kobo Collect one after the other” (IDI/Recorder/Ado LGA).

3.7.2 (ii) Data validation

“At the facility level, we have the recorder and the RI. At the end of the month, they collate their reports, both of them. RI officer and the recorder report to the M&E, the LGA M&E. The RIO reports to the CCO and the LIO. The LGA M&E, the LIO, and the CCO will now look at the data again before uploading to the DHIS”. (IDI/Assistant Technical Adviser/Ekiti State).

“They have an OPD register, tally sheet, and immunization register which they work on … immediately a child is brought to the facility and that child is being attended to, they record it immediately, and when they have collected all their data they bring it together and come for the validation meeting where they will look at what they have done, the M&E officer will be there, the CCO will be there too if the number of vaccines collected correspond with what they used”. (IDI/LIO/Gbonyin LGA).

“We ensure our work tallies, if our work does not tally, we won't be able to present quality data”. (IDI/Recorder/Ifelodun LGA)

3.8 PHC financing

Participants believe that the financial support offered to health workers was highly commendable, as that was a major agent of encouragement for health workers to remain dedicated and committed to their work. Additionally, participants emphasized that payments were made to all healthcare workers involved in the intervention across all levels to ensure the optimization of COVID-19 vaccination into routine immunization, yielding a subsequent seamless implementation and operation of the intervention. As such, participants stated that:

“They tried. I explained earlier that they motivated us— financial support is part of it. Because it helps to make transport convenient, and even minor things like getting water when you’re thirsty. So, this helped to keep us motivated” (IDI/Routine Immunization Focal Person/Ikole Ekiti LGA).

“Sydani Group, as I’ve said, has done well because I can see that they are the ones that have sponsored and spent much on this integration. All the teams that have worked, both the facility and outreach teams and even at the LGA levels, received stipends at the end of the month, including the EMID and the Validators, as Sydani paid for their data and everything they used. So, this aids in the effectiveness of the program”. (IDI/LGA Health Education Officer/Emure LGA).

“Sydani supported them with some stipends and the stipend was based on target. There was a daily target for the teams, including the outreach and the fixed-post teams. The fixed-post team had a daily target of getting at least 7 people vaccinated before they could lay claim to the financial aspect of it for the day”. (IDI/Assistant Technical Adviser/Ekiti State).

3.9 Leadership and governance

Responses from the participants revealed the existence of a structured leadership system that was employed for accountability and transparency during the implementation of the intervention. In doing so, there were supervisory roles at different levels to ensure standard and adequate supervision of the provider of the immunization and vaccination services (i.e. the facility health workers). In other words, participants expressed that:

“Well with the planning, we had LGA, state, and National level supervisors. Based on that, national supervisors in the state were paired with state supervisors and distributed to different local governments for supervision. At the LGA level the MOH, LGA health secretaries, deputy program officers, and the M&E are all the supervisors. And then at the ward level, health management–chairman, and health management committee of that facilities are part of them. So, we distribute ourselves across the teams for supervision. Then we use the ODK app for supervision”. (IDI/M&E Officer/ESPHCDA).

“The LGA team tried because we were doing on-the-job supervision and training for them, they indeed went for training but we still guided them and corrected them with love,, we showed them how they ought to do it if need be and about data entry, we asked them “why have all these data not been entered?” and if she said “it’s because of the network”, as there are some communities with poor networks actually, we would encourage them that immediately they get to the town they should upload the data and we follow up if they have uploaded it”. (IDI/LGA Immunization Officer/EMURE LGA).

“My perception of the supervisory role is that they tried. Because there is a proverb that says that one who must catch a monkey must act like a monkey. We are not perfect people, but I’m grateful that our bosses played good leadership roles. When they see that we seem tired, they call us themselves and encourage us. So that leadership role they carried out, was good for us”. (IDI/Routine Immunization Focal Person/Ikole Ekiti LGA).

3.10 Barriers to the integration of COVID-19 and routine immunization

This study assessed the barriers to integrating COVID-19 vaccination into routine immunization using the WHO Health System Building Blocks framework. Specifically, the study utilized the WHO framework to understand some of the challenges experienced during the implementation exercise in Ekiti state.

3.10.1 Service Delivery

Under the service delivery component, responses from the study participants indicated three key issues experienced during the program implementation. These include rumors, demand for palliatives, and complaints about adverse events following immunization.

3.10.2 (i) Rumors

Participants emphasized that a fundamental barrier they experienced among community residents was rumors about COVID-19 vaccination in the state. The study participants reported that the propagating rumors slightly influenced their coverage, believing their recorded coverage could have been higher without the pervading rumors among people at the grassroots level. However, efforts were made by the team to debunk some of these rumors.

“The major challenge that we faced at that time with the issue of service delivery was the issue of rumor. It affected our service delivery. Because some people have heard rumors about the vaccines, especially the COVID-19 vaccine, that those taking it, may be taking it to cause one problem or the other. Some even said that after two years, those who took the vaccine may die from it”. (IDI/LGA Immunization Officer/Ifelodun LGA).

“When we had almost finished the process, different rumors began to fly around, and people did not want to take the vaccine anymore. We had to explain the concept of the spaced doses to them and dispel the rumor to help people continue coming for their doses”. (IDI/Routine Immunization Focal Person/Ikole Ekiti LGA).

3.10.3 (ii) Demand for Palliatives

Participants further shared their experiences with the caregivers and in some cases, reports from the outreach teams on the demand of community residents. According to the participants, community dwellers believed that health workers had received their share of the palliatives, while community dwellers were abandoned to their fates. This was evident from the following responses:

“We are just sacrificing our time and everything, when the VC/supervisor of health can be saying that, think of so many that will be happening in the field, many insulting words saying we did not give them palliatives that we and our families have finished the palliative, and we are now bringing vaccines to them” (IDI/LGA Immunization Officer/EMURE LGA).

“The caregiver always insults us saying we only give them injections, we don’t give them food and whenever we go for awareness, they always ask us if we will give them money, the people we want to give vaccines to help their health, they ask for money for food, these are the challenges we are facing”. (IDI/Recorder/Ikere LGA).

3.10.4 (iii) Adverse Events Following Immunization

The study participants also revealed that the complaint of Adverse Events Following Immunization (AEFI) either by a resident who had received one dose or by some of the community residents acted as a deterrent to other community residents. This affected the optimization of COVID-19 vaccination into routine immunization in the visited communities.

“The challenge we faced was that some patients refused to take the vaccine because of the adverse effect of the first dose and we enlightened them on the benefit of completing the dosage, some even said they wouldn’t take it because they had seen someone who got vaccinated and had a severe temperature and the likes, but we keep educating them and many end up taking the vaccine”.(IDI/Recorder/Ijero LGA).

“Some people said they don't want to be vaccinated because they heard rumors that the vaccine is affecting some people in the community, and they do not want to start complaining”. (IDI/Recorder/Ido LGA)

To address the challenges experienced under service delivery by the team the following activities were deployed:

  1. i.

    Persuasion through the support of the community leaders, and

  2. ii.

    Health Education

Generally, participants emphasized that to address their challenges in service delivery, they had to persuade community members and educate them where necessary. Participants also added that in some cases, they worked with the community leaders who aided the persuasion given to the community residents before they could eventually go ahead to get them vaccinated or immunize their children.

“We then begin to persuade them and let them know that we did not benefit from any palliative needless to say to give people. We also let them know that even if they are being given palliatives, it will finish in days, and we encourage them to receive the vaccine that can enable them to live a healthy life. We educate them on how these vaccines can prevent some diseases from affecting their health”. (IDI/LGA Immunization Officer/EMURE LGA).

“We did immense work before we could convince our people. That was why I said we involved all the leaders in the community. They are the ones who assisted us in being able to talk to our people in this area. We successfully convinced them in the end, and they all took it. Most of them took the vaccine” (IDI/LGA Immunization Officer/IGbonyin LGA).

3.10.5 Health workforce

Participants in their interviews reported that the major barrier they experienced under the health workforce component was the shortage of health workers. According to the interviewees, the lack of manpower resulted in an increased workload burden amongst the available health workers in the facilities. This is evident in the following expressions by the health workers interviewed.

“We have a shortage of staff in all the health facilities. This is in all the health facilities across the LGAs in the state. For instance, normally, a trained health worker at a fixed post is expected to take delivery of a pregnant woman, there should be another staff responsible for COVID-19 vaccination, and there is usually a roaster for who will be there in the morning and for RI. However, we will be there in the morning and afternoon with no roaster because of the special assignment. We have to be there from morning till evening. Because you will have a lot of work to do, as there's no staff to fix those gaps” (IDI/LGA Immunization Officer/Oye LGA).

“When the process was on, the number of us available did the job well, but if we were more in number, it would have been more efficient. For example, fixed post people like us—a vaccinator and a recorder are at the fixed post, and you know there will be times that the work will be too much, and they’ve told us that our clients must not be kept waiting at the facility. If we had enough hands, we would attend to the clients faster. Although those available tried significantly. If the staff is increased, the work will be faster”. (IDI/Routine Immunization Focal Person/Ikole Ekiti LGA).

3.10.6 Health information system

Findings from the study interview revealed that, despite the electronically structured reporting system that was developed for them to utilize in reporting the data for COVID-19 vaccination into routine immunization, two major hindrances to this system were a lack of gadgets such as laptops and tablets, and poor network services on the part of the various service providers that operate in the state. The following are the findings from the study:

3.10.6.1 (i) Poor network

Participants emphasized that poor network services affected the reporting rate of the data they have acquired, which in some cases may affect their performance. Senior-level health officials highlighted that network issue sometimes results in health workers entering data inadequately on the expected platform(s).

“The network issue is fundamental. At times, at the state level, they will call us, expecting our report, but because of the network, we could not send it in time. We have undulated places, valleys, and other things within my local government that affect the network. That was the major challenge. Some work will be sent to the national or state level at midnight, which is not supposed to be like that”. (IDI/LGA Immunization Officer/Ijero LGA).

“Normally, we do evening review meetings. I collect and collate all the template data that was sent manually. But for us to get the EMID data downloaded, it is giving us a big problem because of the network challenge… In some areas with service, the network will not be okay. I know this because sometimes when they ask me to go to some LGA, to find out what is going on, I find that when I collect the Android phone they use, the data is stored in their local server with them. But for them to get the internal network to upload it to the national server, is a big problem”. (IDI/M&E Officer/ESPHCDA).

3.10.7 Leadership and governance

Participants were equally requested to discuss their challenges in line with the leadership and governance component of the intervention in line with the health building blocks. According to health workers at the supervisory level, bad roads, and lack of designated transportation were two main issues that the team experienced.

3.10.7.1 (i) Bad road networks

Health workers at the supervisory level expressed their worries over the nature of the existing road network in some local government areas across the state. These roads, according to them are not motorable, and evidence from the study is presented below.

“We have the challenge of mobility for example, if I want to go for supervision I cannot allow anyone to mount the bike with me because the roads are not motorable, especially during the rainy season, there was a day I was going for supervision in Alapoto (a remote area), I almost fell, and I had to hold on to a tree and I was later helped down, imagine if we were two (2) on the bike, we could have fallen into the water. So, the roads are bad, and some communities are very far away, I have been injured before when I fell from a bike”. (IDI/LGA Immunization Officer/Emure LGA).

“The only challenge is the poor road network to these health facilities. That is the only challenge we surely face”. (IDI/LGA Health Education Officer/Ikere LGA)

3.10.7.2 (ii) Lack of designated transportation for supervision

The participants also expressed their worries over not having a designated transportation system to aid their supervisory visits to the communities and LGAs across the states. Participants equally tied the unavailability of a transportation system to bad roads and the cost of transportation.

“There is no vehicle for supervision in Ekiti state. We don't have vehicles for supervision. If I'm going for supervision now, it's either I use my car or I go in public transport”. (IDI/ State Immunization Officer/ESPHCDA).

“The only challenge I can think of is that we do not have a transport system in place that can take us to the facilities because transportation is costly, and there are some places where we give COVID-19 vaccinations that are not motorable”. (IDI/Recorder/Oye LGA).

4 Discussion

Following our intervention in Ekiti State, with the support of the State Primary Healthcare Development Agency (ESPHCDA), our study explored the enablers and barriers to integrating COVID-19 vaccination into the routine immunization programme in Ekiti state, Nigeria. In assessing the enablers and barriers of the integration approach, the study adopted the six components of the WHO Health Building Blocks Framework.

Our study found that health workers at the facility, LGA, and state levels are well-acquainted with the idea of integrating COVID-19 vaccination into routine immunization as they shared similar definitions of the concept to mean the addition of COVID-19 vaccination into routine immunization. This corroborates the assertion of the World Health Organization [17] which defined integration as the “adoption (partial or full) of COVID-19 vaccination into national immunization program services, PHC, and any other relevant health services with the overall aim of improving program efficiency and sustainability, enhancing demand and improving user satisfaction, achieving and maintaining satisfactory coverage, and addressing inequities This could be hinged on the fact that health workers were trained extensively on the concept of integration and the implementation of such an approach in the optimization of COVID-19 vaccination into routine immunization in the state. Furthermore, this implies that the participants are actually in the know about the events unfolding around them and are equally up to the task.

All the categories of participants (at the facility, LGA, and state levels) interviewed believed that Ekiti State experienced improved COVID-19 vaccination, and routine immunization coverage upon the adoption of an integrated strategy. This particular notion held by health workers across the three levels might have been informed by the available data on COVID-19 vaccination and routine immunization (before and after adopting the strategy) in the state. This could also be informed by the experiences of health workers at the facility level who might have observed an increase in vaccine uptake among children and their caregivers.

Furthermore, participants agreed with the integration approach of leveraging caregivers’ visitation to the health facility with their child(ren) immunization which ensured the conviction of the former in receiving COVID-19 vaccination either for the first time or for their subsequent dosages. This assertion was influenced by the personal experiences of health workers at the facility, particularly based on their direct interactions with the caregivers. Additionally, participants from our study reported that the integrated efforts of the COVID-19 vaccination into routine immunization resulted in a decline in the prevalence of COVID-19 in the state and the mitigation of vaccine-preventable diseases amongst infant children such as measles.

Findings from the study revealed that to bring life-saving vaccines as close as possible to the people, three themes stood out: demand generation and social mobilization, health education, and vaccine accessibility. Participants from our study highlighted that a preliminary approach to ensuring demand generation was the involvement of key stakeholders such as traditional leaders, religious leaders, political leaders (LGA chairman), and other influential heads of various groups in the state. This is similar to the study [24], which reported that consistent high-level political advocacy and support were significantly critical to improving vaccination uptake in Nigeria. This adopted strategy of obtaining the buy-in of high-level stakeholders (particularly at the community level), by the health workers was informed by the past experiences the health workers have acquired over the years on program implementation.

Subsequently, community sensitizations were conducted, harmonizing various techniques including pre-recorded radio jingles that discussed the benefits and importance of vaccination, and media chats designed to address misconceptions and myths about COVID-19 vaccination. This corroborates a study [28], that employed community dialogue, and TV programs where state residents can call in to ask questions and seek clarifications on the vaccination exercise. The adoption of these strategies might have been influenced by lessons from implementing similar projects either locally or internationally. This could also be an outcome of the synergetic innovative strategies discussed by actors and partners in the state.

Health workers at the facility level leveraged clinic sessions at the various facilities to impart knowledge and foster positive attitudes among the caregivers towards COVID-19 vaccination and routine immunization. This was usually done by conducting health education sessions and sharing Information, Education, and communication (IEC) materials with the caregivers on the importance and benefits of COVID-19 vaccination uptake for the caregivers and the uptake of routine immunization by their wards or children. Our study findings underscore the recommendation [29], suggesting that the awareness of mothers/caregivers should be improved through the design of effective health education about COVID-19, and the distribution of IEC materials prepared in local languages during outreach sessions and at the health facilities. These steps were taken to improve the knowledge base of caregivers on vaccine uptake and address the myths and misconceptions they might hold about the COVID-19 vaccines.

Our study also found that health workers ensured the accessibility of COVID-19 vaccines and immunization antigens to the community residents far and near, through the adoption of a fixed-post vaccination section with health workers domiciled at the facilities to attend to clients, and outreach vaccination sections where health workers visit residents in hard-to-reach settlements. This strategy was employed to optimize the uptake of COVID-19 vaccination and routine immunization, and, to encourage community residents willing to accept the vaccines but are confronted with other challenges hindering them from visiting the health facilities.

Health workers reported that their involvement in organized training to develop their knowledge base on integrating COVID-19 vaccination into routine immunization helped improve their capacity and the quality of their service delivery. The training organized for health workers was likely premised on the need to develop the capacity of health workers for optimum performance, with the ultimate goal of achieving improved program efficiency on the part of the health workers. Our findings established the work of Subba et al., [30], that the capacity of the healthcare workforce must be built on specific public health emergency response for competencies. Additionally, the training of health workers will also act as a driver of the participation of these health workers in the implementation of the integrated approach strategy. As a way of addressing the shortage in manpower, the state government and local implementing partners engaged ad-hoc staff to strengthen the delivery of the outreach teams towards the optimization of COVID-19 vaccination into routine immunization in Ekiti state.

Highlights from our study findings also indicated that developing a micro plan before implementing the intervention fostered the consistent availability of material and vaccines for health workers in executing their activities for the integrated approach. This supports empirical study [24, 31, 32].

A Bottom-up data recording and reporting approach using a combination of paper and electronic tools. Our study found a concurrent reporting of COVID-19 vaccination into routine immunization data through a unified platform without data mixing. Additionally, findings from our study revealed that data verification and validation were drivers of timely and complete reporting of COVID and RI data among the teams in the state. This aligns with Tella-Lah et al. [33] who revealed that the EMID system optimization and integration of COVID-19 vaccination into routine immunization data into one system has significantly increased the number of vaccinations documented in Nigeria.

The participants significantly appreciated the financial support offered to them across all levels, as they considered it a form of motivation that spurred them to work more and push for the optimization of COVID-19 vaccination into routine immunization. This further asserts the study of Nyaboga and Muathe [34], whose findings ranked remuneration as having the major impact on performance among healthcare workers in Keyan’s public hospital. The approach of performance-based financing adopted by the partners for health workers at the grassroots level was significantly influential in the desire of health workers to get more people vaccinated, thereby translating to increased coverage.

Additionally, supervision was spread across three different levels to ensure accountability and transparency in the operationalization of integrating COVID-19 into RI. This structured level (federal, state, and LGA) of supervision adopted created a form of check and balance among key actors in the intervention implemented in Ekiti state supporting the recommendation of UNICEF, [35] that tier-based supervision is essential to immunization. Additionally, the supervision conducted at the facility level equally acted as a form of on-the-job training for health workers at the facility level.

Three key issues significantly affected the health workers in driving service delivery to optimize integrating the COVID-19 vaccination into routine immunization. These were rumors (myths and misconceptions), demand for palliatives, and adverse events following immunization. This corroborates the findings of Nabia et al., [36], who reported that vaccine hesitancy was usually due to misinformation and side effects, among others, in Sudan and the USA. The interviewees, especially at the facility level, also shared that, certain caregivers or community residents were deterred from taking the vaccine upon learning that a few caregivers experienced Adverse Events Following Immunization (AEFI). Health workers found this particularly challenging, as this confused caregivers with the existing rumors on COVID-19 vaccines in their communities. Despite these challenges, health workers managed to convince the caregivers of the value and importance of accepting the vaccination, particularly by leveraging on key stakeholders in the community.

Participants vehemently complained about the lack of skilled manpower. Although ad-hoc staff were engaged during the program implementation, they only possessed skills in areas other than health services and could only support outreach vaccination sessions. Therefore, the void still exists at the health facility level with a limited number of skilled health workers present in the facility to offer services other than vaccination or immunization resulting in work overburden. This alludes to the findings of Atobatele et al. [37] who reported the availability of manpower as one of two key enablers of integrating health interventions. This could potentially result in burnout syndrome among health workers in such a situation. Hence, the government must conduct a human resource for health (HRH) gap analysis to identify areas or specializations where health workers are needed more.

The study observed the need for improved network/internet services, and minimal data subscriptions for health workers as the mobile teams experienced few hiccups during the implementation of the vaccination strategy. Although study participants mentioned that they were motivated, well-renumerated, and incentivized, the reality is that the current economic situation of Nigeria has further depreciated the purchasing value of her currency. Hence, there is a need for future projects to improve the welfare or remuneration of health workers or outreach teams in similar studies. Our study found that bad road networks are imminent threats to the supervision of health workers at the grassroots level, particularly within the various hard-to-reach communities. This alludes to the fact that several rural road networks are not frequently maintained and are usually deteriorating over the years [38, 39].

5 Conclusion

Our study assessed the enablers and barriers of integrating COVID-19 vaccination into routine immunization in primary healthcare facilities in Ekiti State. The findings underscored the positive impact of this integration on vaccination coverage, outbreak prevention, and the strengthening of the health system.

Adequate training and preparedness of the healthcare workers, demand generation activities, health education, vaccine availability, and accessibility significantly contributed to the success of the integration program. Early involvement of key stakeholders secured the required support, as the development of micro plans ensured efficient service delivery. The Bottom-up data recording approach and concurrent reporting on a unified platform showcased a robust health information system facilitating accurate data reporting. Challenges identified, include rumors, demand for palliatives, and adverse events after vaccination. The scarcity of skilled manpower, and poor network services, were identified as the barriers experienced in the program. Additionally, infrastructural and logistic challenges, such as bad road networks and lack of designated transport for supervision, were also highlighted.

Study Limitation.

One limitation experienced during this study was the unavailability of two eligible study participants at the state level during the interviews. These high-ranking officials could have provided more insights into the enablers and barriers of integrating COVID-19 vaccination into RI. Additionally, the study could not delve into understanding the nuances of the sustainability plan to be espoused in the state to maintain the integration of COVID-19 into RI and other PHC services in the state.

5.1 Recommendations

Recommendations emanating from this study include the government at the national and sub-national levels addressing manpower shortage through HRH gap analysis and recruitment of skilled staff. The provision of improved network services will enhance data reporting. The government should invest in transport systems for easy mobility to ensure sustained success and strengthen the integration strategy in the battle against COVID-19 and other vaccine-preventable diseases in Ekiti State. Consequently, the publication of a National handbook on integrating COVID-19 vaccination into routine immunization and other PHC services will equally optimize health service delivery in primary healthcare facilities, and other health facilities across the country.

Furthermore, subsequent studies on the integration of COVID-19 into routine immunization could feature clients (caregivers of children eligible for immunization and/or eligible adults for COVID-10 vaccination).