The intervention was carried out between May 2017 and November 2018). It had multiple components which were designed to fit the structure of the primary healthcare system via the ward development committee. The Committee was composed of members of the community including traditional and religious leaders (TRL). The ward development committees provide oversight to the primary healthcare facilities.

The intervention included training of the TRLs as a means of improving their leadership role in the community and in the ward development committee and their knowledge and perspective on vaccination. The components of the intervention were: TRL training, Health workers’ training, community engagement and strengthening of the ward development committee.

The preparatory phase lasted for five months during which the training tools were prepared, and pilot tested. The training tools were developed by the research team by adapting existing national and international tools [10, 11]. The adapted tools were reviewed by the training team who comprised four retired Community Health Officers who were experienced health educators and community mobilizers, and had worked either as Primary Health Care Coordinators or Social Mobilization Officers. Pilot testing of the tools was carried out in one of the Local Government Areas in the State that was not included in the study, with five traditional and three religious leaders in attendance. The aims were to test the ability of the trainers to communicate the training objectives and to get feedback from the trainees on their understanding of the objectives of the training and the usefulness of the training materials to improve knowledge and perspective on vaccination.

The training was conducted at the LGA level for TRLs from the selected villages. A total of 23 participants were trained in each of the four intervention LGAs. This comprised all the village heads in the selected villages and the Clan Head from the selected Wards and two religious leaders from each Ward. None of the selected participants held dual offices. The majority of the religious groups were Christians; only Obudu, an LGA in the northern senatorial district, had an Islamic religious leader. Two religious leaders with the largest followers and the leader of the only Islamic group were invited to participate in the training in each Ward.

The venue of the training was the primary healthcare facility in three LGAs and the town council hall in one LGA. Training sessions included types of leadership, characteristics of a good leader, transformational leadership, effective communication, vaccination, community mobilization, etc. All the participants were literate and could be communicated with in Nigerian Pidgin (also called Nigerian Creole), which is an informal English-based creole language spoken as a lingua franca across Nigeria. The sessions were interactive and participatory. Methods of training adopted included brainstorming, large and small group discussions, role-plays, problem-solving case studies, and learning aids. Five sessions of training were held in the first nine months and three sessions in the second nine months. No training was conducted for traditional and religious leaders in the control sites.

The training was conducted for the health workers in the intervention sites to improve the quality of their summarization and communication of vaccination data with laypersons. The cadres of health workers were the Senior Community Health Extension Workers and Community Health Extension Workers. A one-day training session on data summarization and presentation using infographic aid was held in one of the Health Centres in each intervention LGA. The participants were the health workers in charge of the Health Centres from the three Wards included in the study, the Ward Focal Person, the Local Immunisation Officer, the Monitoring and Evaluation Officer, and the Cold Chain Officer. The training lasted for three hours. Data from the immunisation registers generated from routine services in health facilities were analysed and presented on a dashboard. The dashboard was a portable 60 by 70 cm plastic panel with stick-on plaques for ease of conveyance to meetings outside the health facility. The health workers used this to share data with the TRLs at Council of Chiefs’ meetings and the ward development committee meetings. Data displayed on the dashboard included monthly RI uptake and dropouts on the Pentavalent 3 vaccine. Hands-on training was also conducted for the health workers on keeping a defaulters’ register following a report from them that they did not have a means of identifying children that had dropped out of immunisation. This training was delivered on the fifth month of the intervention. They were also trained on the management of adverse effects of vaccination. No training was conducted for health workers in the control sites.

The TRLs in the intervention sites educated their communities during their routine community meetings on vaccination. In addition, vaccination data summarized by the health workers from RI services were displayed on the dashboard and shared during the monthly ward development committee meetings. The religious leaders utilized the church and the mosque to share information with the community. Similar community meetings were held routinely in a monthly basis in the control sites. However, the information on vaccination was not shared.

As at the time of commencement of the intervention, the ward development committees had become inactive in most of the Wards in the intervention sites following non-support of the Committees’ meetings by the government: only 3 of the 12 were functioning. Following the training, the nine non-active ward development committees were reactivated and began holding regular meetings. The ward development committees in the control sites were holding regular meetings devoid of the trial related intervention on vaccination.

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