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Community -Based Intervention to reach the last mile of childhood vaccination coverage in Rwanda: Case study of Burera district

Michee Nshimayesu, Barnabas Tobi Alayande, Marie Consolatrice Sage Ishimwe, Aimable Uwimana, Charif Niyiragira et al. · 25 May 2025

Abstract

Abstract Background Vaccination remains a cornerstone of global child health, offering one of the most cost-effective interventions for reducing childhood morbidity and mortality caused by vaccine-preventable diseases (VPDs). Despite this, global vaccination coverage has recently declined, particularly in low- and middle-income countries. In Rwanda, although the national childhood immunization rate has reached 95%, gaps remain in reaching the last mile. Community Health Workers (CHWs) have played an instrumental role in promoting and delivering immunization services across hard-to-reach communities. Yet, little is known about the specific contributions of CHWs to these gains, particularly in rural settings such as Burera District, Northern Rwanda. The study aimed to (1) investigate the factors influencing CHWs’ intervention in promoting childhood vaccination, (2) examine the impact of CHWs on vaccination coverage among children under five, and (3) explore the perspectives of caregivers on CHWs’ intervention in childhood vaccination coverage. Methods A mixed-methods approach was adopted, combining quantitative surveys with 345 CHWs and qualitative key informant interviews (KIIs) with selected caregivers of children under five benefiting from CHWs vaccination intervention. Quantitative data were collected through structured questionnaires and analyzed using descriptive statistics, and multivariable logistic regression in STATA 18. Thematic analysis was used to analyze qualitative data obtained from five KIIs across Burera’s five major health center catchment areas. Results CHWs in Burera were predominantly female (67.5%), married (98.8%), with primary-level education (86.1%), and most engaged in farming (98.6%). A large proportion (94.5%) had received training on vaccination services, and 98.3% regarded under-five vaccination as “very important.” Over 50% reported facilitating community vaccination events twice per month. CHWs were actively involved in community mobilization and advocacy, with 93.9% participating in campaign planning. CHW activities included referring children to health facilities (58.0%) and conducting home-based vaccination outreach (42.0%). From caregivers’ perspectives, CHWs played critical roles in health education, timely reminders for appointments, and home-based vaccination services. Thematic analysis of interviews revealed strong trust in CHWs, who were seen as vital liaisons between the community and the formal health system. Barriers noted included logistical challenges and the need for more consistent training and communication support for CHWs. Over 55% of CHWs recommended more structured community awareness campaigns to further enhance immunization uptake. Conclusion CHWs are central to Rwanda’s success in achieving high childhood vaccination coverage, especially in rural areas like Burera District. Their interventions in education, mobilization, and service delivery have significantly contributed to bridging gaps in access and awareness. However, sustaining and enhancing these gains requires continued investment in CHW training, supervision, and logistical support. Findings from this study provide critical insights for policymakers and health planners to strengthen community-based vaccination strategies and reach the last mile by 2030 in alignment with Sustainable Development Goal (SDG) 3.b.