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Background: Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era"., Methods: Drawing on lessons from case studies of large well-established CHW programmes, published literature, and the authors' experience, the paper highlights major issues that need to be acknowledged to design and deliver effective CHW programmes at large scale. The paper also serves as an introduction to a set of articles addressing these issues in detail., Results: The article highlights the diversity and complexity of CHW programmes, and offers insights to programme planners, policymakers, donors, and others to inform development of more effective programmes. The article proposes that be understood as actors within community health system(s) and examines five tensions confronting large-scale CHW programmes; the first two tensions concern the role of the CHW, and the remaining three, broader strategic issues: 1) What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? 2) Lay versus professional? 3) Government programme at scale or nongovernmental organization-led demonstration project? 4) Standardized versus tailored to context? 5) Vertical versus horizontal?, Conclusion: CHWs can play a vital role in primary healthcare, but multiple conditions need to be met for them to reach their full potential., (© 2021. The Author(s).)

Background: This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era"., Methods: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes., Results: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness., Conclusion: A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All., (© 2021. The Author(s).)

Background: Community health workers (CHWs) can play a critical role in primary healthcare and are seen widely as important to achieving the health-related Sustainable Development Goals (SDGs). The COVID-19 pandemic has emphasized the key role of CHWs. Improving how CHW programmes are governed is increasingly recognized as important for achieving universal access to healthcare and other health-related goals. This paper, the third in a series on "Community Health Workers at the Dawn of a New Era", aims to raise critical questions that decision-makers need to consider for governing CHW programmes, illustrate the options for governance using examples of national CHW programmes, and set out a research agenda for understanding how CHW programmes are governed and how this can be improved., Methods: We draw from a review of the literature as well as from the knowledge and experience of those involved in the planning and management of CHW programmes., Results: Governing comprises the processes and structures through which individuals, groups, programmes, and organizations exercise rights, resolve differences, and express interests. Because CHW programmes are located between the formal health system and communities, and because they involve a wide range of stakeholders, their governance is complex. In addition, these programmes frequently fall outside of the governance structures of the formal health system or are poorly integrated with it, making governing these programmes more challenging. We discuss the following important questions that decision-makers need to consider in relation to governing CHW programmes: (1) How and where within political structures are policies made for CHW programmes? (2) Who implements decisions regarding CHW programmes and at what levels of government? (3) What laws and regulations are needed to support the programme? (4) How should the programme be adapted across different settings or groups within the country or region?, Conclusion: The most appropriate and acceptable models for governing CHW programmes depend on communities, on local health systems, and on the political system in which the programme is located. Stakeholders in each setting need to consider what systems are currently in place and how they might be adapted to local needs and systems., (© 2021. The Author(s).)

Background : Lay health workers (LHWs) are critical in linking communities and primary healthcare (PHC) facilities. Effective communication between facilities and LHWs is key to this role. We implemented a mobile health (mHealth) system to improve communication and continuity of care for chronically ill clients. The system focused on requests from facility staff to LHWs to follow up clients and LHW referrals of people who needed care at a facility. We implemented the system in two rural and semi-rural sub-districts in South Africa. Objective : To assess the feasibility of the mHealth system in improving continuity of care for clients in PHC in South Africa. Method : We implemented the intervention in 15 PHC facilities. The clerks issued recalls to LHWs using a tablet computer. LHWs used smartphones to receive these requests, communicate with clerks and refer people to a facility. We undertook a mixed-methods evaluation to assess the feasibility of the mHealth system. We analysed recall and referral data using descriptive statistics. We used thematic content analysis to analyse qualitative data from semi-structured interviews with facility staff and a researcher fieldwork journal. Results : Across the sub-districts, 2,204 clients were recalled and 628 (28%) of these recalls were successful. LHWs made 1,085 referrals of which 485 (45%) were successful. The main client group referred and recalled were children under 5 years. Qualitative data showed the impacts of facility conditions and interpersonal relationships on the mHealth system. Conclusion : Using mHealth for recalls and referrals is probably feasible and can improve communication between LHWs and facility staff. However, the low success rates highlight the need to assess facility capacity beforehand and to integrate mHealth with existing health information systems. mHealth may improve communication between LHWs and facility staff, but its success depends on the health system capacity to incorporate these interventions.

Purpose: This study was designed to evaluate the feasibility of a cluster randomized controlled trial to test the efficacy of lay health workers (LHWs) in improving the uptake and completion of pulmonary rehabilitation (PR) in the treatment of COPD., Materials and Methods: LHWs, trained in confidentiality, role boundaries, and behavior change techniques, supported patients newly referred for PR. Interactions between LHWs and participants were recorded with smartphones. Outcomes were recruitment and retention rates of LHWs, questionnaire and interview-evaluated acceptability and analysis of intervention fidelity., Results: Forty (36%) of 110 PR-experienced COPD patients applied to become LHWs. Twenty (18%) were selected for training. Twelve (11%) supported patients. Sixty-six COPD patients referred for PR received the intervention (5.5 participants per LHW). Ten LHWs were retained to the end of the study. Seventy-three percent of supported patients were satisfied or very satisfied with the intervention. LHWs delivered the intervention with appropriate style and variable fidelity. LHWs would welcome more intensive training. Based on this proof of concept, a cluster randomized controlled trial of an LHW intervention to improve uptake and completion of PR is feasible., Conclusion: PR-experienced COPD patients can be recruited, trained, and retained as LHWs to support participation in PR, and can deliver the intervention. Participant COPD patients found the intervention acceptable. A cluster randomized controlled clinical trial is feasible., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Formative programme evaluations assess intervention implementation processes, and are seen widely as a way of unlocking the 'black box' of any programme in order to explore and understand why a programme functions as it does. However, few critical assessments of the methods used in such evaluations are available, and there are especially few that reflect on how well the evaluation achieved its objectives. This paper describes a formative evaluation of a community-based lay health worker programme for TB and HIV/AIDS clients across three low-income communities in South Africa. It assesses each of the methods used in relation to the evaluation objectives, and offers suggestions on ways of optimising the use of multiple, mixed-methods within formative evaluations of complex health system interventions., Methods: The evaluation's qualitative methods comprised interviews, focus groups, observations and diary keeping. Quantitative methods included a time-and-motion study of the lay health workers' scope of practice and a client survey. The authors conceptualised and conducted the evaluation, and through iterative discussions, assessed the methods used and their results., Results: Overall, the evaluation highlighted programme issues and insights beyond the reach of traditional single methods evaluations. The strengths of the multiple, mixed-methods in this evaluation included a detailed description and nuanced understanding of the programme and its implementation, and triangulation of the perspectives and experiences of clients, lay health workers, and programme managers. However, the use of multiple methods needs to be carefully planned and implemented as this approach can overstretch the logistic and analytic resources of an evaluation., Conclusions: For complex interventions, formative evaluation designs including multiple qualitative and quantitative methods hold distinct advantages over single method evaluations. However, their value is not in the number of methods used, but in how each method matches the evaluation questions and the scientific integrity with which the methods are selected and implemented.

Background: Lay or community health workers (LHWs) are an important human resource in primary health care, and contribute to improving access to care. However, optimal use of LHWs within the health system is often hampered by a poor understanding of how this cadre organizes its work. This study aimed to better understand how LHWs organize and structure their time in providing treatment and adherence support to people on TB treatment and/or antiretroviral therapy (ART) in South Africa., Methods: Fourteen LHWs participated across three low-income peri-urban communities in Cape Town. Each LHW was observed by a researcher for one day, and data collected on each activity and the time spent on it. Data were summarized in the following categories: travel to the patient's home, waiting time and patient contact time., Results: Ninety-seven attempted visits to patients were observed, and patients were located in 69 of these. On average, LHWs conducted six visits per day, each lasting an average of nine minutes. Forty-six percent of the observed time was spent with patients, with the balance spent on 'non-contact' activities, including walking to and waiting for patients. The average walking time between patients was 8 minutes (range: 3 to 15 minutes). Activities during visits comprised medical care (that is ensuring that medication was being taken correctly and that patients were not experiencing side-effects) and social support. Other tasks included conducting home assessments to determine risks to treatment adherence, and tracing patients who had defaulted from treatment., Conclusions: Because of their tasks and working environment, LHWs providing support to people on TB treatment and ART in South Africa spend a substantial proportion of their time on 'non-contact' activities. Programme managers need to take this into account when developing job descriptions and determining patient case-loads for this cadre. More research is also needed to explore whether these findings apply to other tasks and settings. Strategies should be explored to mitigate the challenges that LHWs experience in locating and supporting patients, including the use of new technologies, such as mobile phones.

Background: Lay health workers (LHWs) perform functions related to healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child health., Objectives: The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child health., Search Methods: We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In-Process & Other Non-Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review., Selection Criteria: Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child health in a primary or community healthcare setting., Data Collection and Analysis: We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness., Main Results: We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other health workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications.Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty.Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs' skills and the similarities they saw between themselves and the LHWs. However, some recipients were concerned about confidentiality when receiving home visits. Others saw LHW services as not relevant or not sufficient, particularly when LHWs only offered promotional services. LHWs and recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from health systems and community leaders could give LHWs credibility, at least if the health systems and community leaders had authority and respect. Active support from family members was also important.Health professionals often appreciated the LHWs' contributions in reducing their workload and for their communication skills and commitment. However, some health professionals thought that LHWs added to their workload and feared a loss of authority.LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints. LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling for more training in counselling and communication and in topics outside their current role, including common health problems and domestic problems. LHWs and supervisors complained about supervisors' lack of skills, time and transportation. Some LHWs appreciated the opportunity to share experiences with fellow LHWs.In some studies, LHWs were traditional birth attendants who had received additional training. Some health professionals were concerned that these LHWs were over-confident about their ability to manage danger signs. LHWs and recipients pointed to other problems, including women's reluctance to be referred after bad experiences with health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co-operation with health professionals.We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long-term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success., Authors' Conclusions: Rather than being seen as a lesser trained health worker, LHWs may represent a different and sometimes preferred type of health worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the health system and the community; and appropriate training, supervision and incentives.

Background: Qualitative research is used increasingly alongside trials of complex interventions to explore processes, contextual factors, or intervention characteristics that may have influenced trial outcomes. Qualitative research conducted alongside trials can also be used to shed light on the results of systematic reviews of effectiveness by looking for factors that can help explain heterogeneous results across trials. In a Cochrane review on the effects of using lay health workers on maternal and child health and infectious disease control, we identified 82 trials. These trials showed promising benefits but results were heterogeneous., Objective: To use qualitative studies conducted alongside these trials to explore factors and processes that might have influenced intervention outcomes., Methods: We attempted to identify qualitative research carried out alongside the trials by contacting trial authors, checking papers for references to qualitative research, searching Pubmed for related studies, and carrying out citation searches. For those qualitative studies that we included, we extracted information regarding study objective, data collection and analysis methods, and key themes and categories., Results: For 52 (63%) of the trials, we found no qualitative research that had been conducted alongside the trials. For 16 (20%) trials, some form of qualitative data collection had been done but was unavailable or had been done before the trial. For 14 (17%) trials, qualitative research had been done during or shortly after the trial, although descriptions of qualitative methods and results were often sparse. Most of these 14 studies aimed to elicit trial participants' perspectives and experiences of the intervention. A common theme was participants' appreciation of the lay health workers' shared circumstances, for instance with regard to social background or experience of the health condition. In six studies, researchers explored the experiences of the lay health workers themselves. Issues included the importance of regular supervision and health professionals' support or lack of support., Conclusions: Qualitative studies carried out alongside trials of complex interventions could offer opportunities to authors of systematic reviews of effectiveness wishing to understand the heterogeneity of trial results. For interventions of lay health worker programmes at least, too few such studies exist at present for these opportunities to be realised.

There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970s-1994) - a time of innovative initiatives. After 1994, the new democratic government embraced primary healthcare (PHC), however CHW initiatives were not included in their health plan and most of these programmes subsequently collapsed. Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care. Thirteen oral history interviews and eight witness seminars were conducted in South Africa in April 2008 with founders and CHWs from these earlier programmes. These data were triangulated with written primary sources and analysed using thematic content analysis. The study suggests that 1970s-1990s CHW programmes were seen as innovative, responsive, comprehensive and empowering for staff and communities, a focus which respondents felt was lost within current programmes. The growth of these earlier projects was underpinned by the struggle against apartheid. Respondents felt that the more technical focus of current CHW programmes under-utilise a valuable human resource which previously had a much wider social and health impact. These prior experiences and lessons learned could usefully inform policy-making frameworks for CHWs in South Africa today., (Copyright 2010 Elsevier Ltd. All rights reserved.)

The Female Community Health Volunteer (FCHV) Programme in Nepal has existed since the late 1980s and includes almost 50,000 volunteers. Although volunteer programmes are widely thought to be characterised by high attrition levels, the FCHV Programme loses fewer than 5% of its volunteers annually. The degree to which decision makers understand community health worker motivations and match these with appropriate incentives is likely to influence programme sustainability. The purpose of this study was to explore the views of stakeholders who have participated in the design and implementation of the Female Community Health Volunteer regarding Volunteer motivation and appropriate incentives, and to compare these views with the views and expectations of Volunteers. Semi-structured interviews were carried out in 2009 with 19 purposively selected non-Volunteer stakeholders, including policy makers and programme managers. Results were compared with data from previous studies of Female Community Health Volunteers and from interviews with four Volunteers and two Volunteer activists. Stakeholders saw Volunteers as motivated primarily by social respect, religious and moral duty. The freedom to deliver services at their leisure was seen as central to the volunteer concept. While stakeholders also saw the need for extrinsic incentives such as micro-credit, regular wages were regarded not only as financially unfeasible, but as a potential threat to the Volunteers' social respect, and thereby to their motivation. These views were reflected in interviews with and previous studies of Female Community Health Volunteers, and appear to be influenced by a tradition of volunteering as moral behaviour, a lack of respect for paid government workers, and the Programme's community embeddedness. Our study suggests that it may not be useful to promote a generic range of incentives, such as wages, to improve community health worker programme sustainability. Instead, programmes should ensure that the context-specific expectations of community health workers, programme managers, and policy makers are in alignment if low attrition and high performance are to be achieved., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions., Objectives: To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases., Search Strategy: For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers., Selection Criteria: Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients., Data Collection and Analysis: Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained., Main Results: Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective., Authors' Conclusions: LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

The benefits of pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) are restricted by poor uptake and completion. Lay health workers (LHWs) have been effective in improving access to treatment and services for other health conditions. We have successfully shown the feasibility of this approach in a PR setting and its acceptability to the LHWs and COPD patients. We present here the feasibility of assessment, and the fidelity of delivery of LHW support achieved for COPD patients referred for PR. LHWs, volunteer COPD patients experienced in PR, received training in the intervention including communication skills, confidentiality and behaviour change techniques (BCTs). Interactions between LHWs and patients were recorded, transcribed and coded for delivery style and BCTs. Inter-rater agreement on the coding of delivery style and BCTs was high at >84%. LHWs built rapport and communicated attentively in over 80% of interactions. LHWs most consistently delivered BCTs concerning information provision about the consequences of PR often making those consequences salient by referring to their own positive experience of PR. Social support BCTs were also used by the majority of LHWs. The use of BCTs varied between LHWs. The assessment of intervention delivery fidelity by LHWs was feasible. LHW training in the setting of PR should add emphasis to the acquisition of BCT skills relating to goal setting and action planning. [ABSTRACT FROM AUTHOR]

Background: Effective vaccination communication with parents is critical in efforts to overcome barriers to childhood vaccination, tackle vaccine hesitancy and improve vaccination coverage. Health workers should be able to provide information to parents and other caregivers and support them in reaching decisions about vaccinating their children. Limited information exists regarding the perceptions of caregivers and health workers on the vaccination communication strategies employed in Nigeria. This study, which forms part of the ‘Communicate to vaccinate’ (COMMVAC) project, aims to explore the perceptions and experiences of caregivers and health workers in Nigeria on vaccination communication strategies implemented in their settings. Methodology: We conducted the study in two States: Bauchi in Northern Nigeria and Cross River in the south. We carried out observations (n = 40), in-depth interviews (n = 14) and focus group discussions (FGDs) (n = 12) amongst 14 purposively selected health workers, two community leaders and 84 caregivers in the two states. We transcribed data verbatim and analysed the data using a framework analysis approach. Results: Caregivers were informed about vaccination activities through three main sources: health facilities (during health education sessions conducted at antenatal or immunization clinics); media outlets; and announcements (in churches/mosques, communities and markets). Caregivers reported that the information received was very useful. Their preferred sources of information included phone text messages, town announcers, media and church/mosque announcements. Some caregivers perceived the clinic environment, long waiting times and health worker attitudes as barriers to receiving vaccination information.When delivering communication interventions, health workers described issues tied to poor communication skills; poor motivation; and attitudes of community members, including vaccine resistance. Conclusion: Communication about vaccination involves more than the message but is also influenced by the environment and the attitudes of the deliverer and receiver. It is pertinent for health policy makers and programme managers to understand these factors so as to effectively implement communication approaches. [ABSTRACT FROM AUTHOR]