• Where do you work (country, district, city) and what does your work consist of?

I work in Ile-Ife, Osun State, South West, Nigeria. I am a community health physician and my work consist of provision of community-based health services, research and teaching. In the area of health service provision, I provide promotive, preventive, curative and rehabilitative health services at both urban and rural communities. I teach and mentor medical and paramedical students as well as junior resident doctors in the area of public health. I also participate in Lot Quality Assurance Sampling Surveys (LQAS) during supplementary immunisation activities as well as disease surveillance and outbreak investigation and response activities. My research interests are in the area of maternal and child health including immunisation.

• What do you know about the situation of equity and coverage? What else would you need to find out?

Nigeria has the second largest pool of unvaccinated and under-vaccinated children in the world (UNICEF and WHO 2015). According to the 2018 NDHS, only 31.5% of children aged 12-23 months have received all the basic vaccines. In addition to the low national immunisation coverage, geographic and sociodemographic disparities in immunisation coverage also exist across the country. Administratively, Nigeria is divided into 36 states and the federal capital territory. These states are grouped into six geopolitical zones: North-Central, North-East, North-West, South-East, South-South and South-West. Several national surveys have consistently shown that routine immunisation (RI) coverage is relatively lower in the northern part of the country than in the south (MICS 2016-2017, NNHS 2018 and NDHS 2018). For example, RI coverage ranged from 4.5% in Sokoto State, South-West Zone to 75.8% in Anambra State, South-East Zone. Sociocultural and supply side factors have been given as reasons for this geographic disparity in RI coverage. However, as internal migration is a common feature in the country, people do not only migrate from rural to urban communities, they also migrate from their ancestral homes to settle in other parts of the country. One of such people are the Hausas of northern Nigeria origin who migrate to southern Nigeria majorly for economic reasons. Upon migration, some of the Hausas settle in slum communities popularly called ‘Sabo’. These communities are located in major towns and cities in southern Nigeria. Apart from their retention of a culture of low immunisation uptake associated with their northern Nigeria origin, where immunisation coverage is relatively low, language barrier, low level of mother’s education, high rate of non-health facility delivery, low socioeconomic status, poor knowledge of routine immunisation and perceived or real discrimination from health workers put the children in these communities at risk of being marginalised and so missing out on RI. In a recent community-based comparative cross-sectional study carried out in Osun State, South-West, Nigeria, RI coverage among the Hausa children in the Sabo communities was found to be 29% compared with 68% among Yoruba (indigenous) children living in communities contiguous with the Sabo communities. Thirty percent of the Hausa children were unimmunised compared with 5.8% of the Yoruba children. Also, the Penta 1-Penta 3 dropout rate was 27% among the Hausa children compared with 9.7% among the Yoruba children. These statistics indicates inequity in both access and utilisation of RI services between these two groups of children living in the same geographical location. Therefore, there is need to design, implement and evaluate an evidence-based strategy tailored towards the needs of the non-indigenous Hausa subpopulation in the urban areas of Osun State in order to bridge the existing equity gap and improve the overall RI coverage in the State.

• Of the four guidelines that you have reviewed, which is most likely to be relevant and useful to help you improve this situation? Why?

Although all the guidelines are important in one way or the other, I consider the urban immunisation tool-kit to be the most relevant and useful guideline to improve immunisation coverage in the setting described above. This is because the ‘Sabo’ communities where these children live slums located in urban areas where routine immunisation services are available. I believe that the ideas, strategies, links and other resources provided by the tool kit should able to serve as guides in the development of implementable interventions for addressing barriers to access and utilisation of immunisation service in this context.

• Referring to the guideline, what can be done to improve equity and coverage?

Equity and coverage can be improved by adapting the five components of the urban immunisation tool kit to this context. In the planning, coordination and management of resources, stakeholders such as community leaders, religious leaders, women groups and health workers should be involved. Service delivery should be adapted to suit the culture of the target population. In order to reach every eligible child, proper mapping of the communities should be done. It may be necessary to list all eligible children in the population so as to ensure that no child is missed. Continuous tracking of new-borns that are delivered at home should be done by ensuring that all pregnant women are followed up with regular home visits. Appropriate recall system should be instituted to ensure that defaulters are identified and vaccinated promptly. In engaging with communities, specific messages targeting fathers should be developed and used. These messages should be delivered using the appropriate languages and disseminated through appropriate media. This is to reduce incidences of vaccine hesitancy as a result of outright refusal of vaccination which can be attributed to fathers’ belief about vaccination. Quality of service should be improved by establishing a system where clients can provide feedback about service delivery and also by ensuring that appropriate actions are taken to address client concerns. It is also important to ensure adequate supportive supervision of immunisation staff. Lastly, relevant data should be collected to monitor selected coverage and equity indicators in the population.