On a warm morning in Unguwar Rimi, a densely populated neighborhood in Kaduna North, Fatima did what the health system asked of her. She wrapped her nine-month-old son, Abubakar, to her back and walked to the health center for his measles, yellow fever and meningitis A vaccines. She had done this before many times for earlier vaccinations.
“It’s something you have decided to do – anytime you are scheduled, you will try as much as possible to go.”
That day, however, Fatima was told there were too few children present to open the vaccine vial. She was asked to return another day. When she did, the vaccines were finished. After her third attempt, Abubakar developed a fever attributed to teething, and Fatima decided to wait. Days passed. As confidence that a visit would be successful faded, household responsibilities took priority. Abubakar never received his 9-month vaccines.
Fatima’s story is not one of a mother who was unsure about the importance of vaccines, but of a gap between intent and the health system processes needed to consistently convert that intent into vaccination.
Why the 9-month vaccines matter
In Nigeria, children are due to receive their first measles-containing vaccine (MCV1), yellow fever and meningitis A vaccines at 9 months of age. These vaccines protect against highly transmissible, outbreak-prone diseases that continue to affect children across the country. Measles remains endemic, and Nigeria has 3.1 million children – one of the largest numbers of children globally – who have not received a first dose of measles vaccine. MCV1 coverage has stalled at around 60% in recent years, far below the 95% threshold needed to interrupt transmission.
The challenge at 9 months is not simply whether families want vaccines. Even when caregivers successfully complete early-infancy vaccinations and intend to return, the system does not meet their needs.
The five-month silence
Using community-based participatory research, VillageReach and Solina Centre for International Research and Development (SCIDaR) worked with caregivers, heads of household, health workers, community influencers and immunization managers in Kaduna and Enugu States to understand the barriers to vaccination at 9 months.
One insight stood out across both contexts: a long silence. As one community influencer explained, “Caregivers are more concerned about caring for the child when they are younger, but when it reaches 9 months… they have laxity…”
From birth to 14 weeks, families return to the health facility roughly every four weeks. Appointments are written on cards, reinforced by repeated contact with health workers and supported by postpartum care at hom. Then, suddenly, there is little contact until 9 months. No standard reminders for caregivers. No follow-up.
The system’s silence matters. As routines fade and reminders disappear, responsibility shifts from the health system to busy caregivers who have typically returned to work, farming and community obligations. Support from relatives has diminished. The child looks stronger, and urgency declines.
Nigeria is not one story
The research focused on two states, one in the North and one in the South, to understand how context shapes the problem and the solutions.
In Kaduna, gender norms more strongly constrain women’s mobility and decision-making. Many caregivers must seek permission or support from the head of household, often the caregiver’s husband, to attend vaccination, and trusted community and religious leaders play a significant role in shaping health behaviors. Distance to facilities is longer, and vaccine stockouts and restrictive vaccination session scheduling are more frequently reported.
In Enugu, communities are typically closer to facilities, literacy and media access are higher, and gender dynamics are less restrictive. But families face acute opportunity costs from lost income, transport fares and long waits. Staffing shortages and inflexible session schedules can make reliability a challenge.
Despite these differences, the same core pattern emerged: caregivers like Fatima showed up with intent, but were sometimes turned away, delayed or discouraged.
Making the invisible visible
Human-centered design was essential to uncovering these dynamics. Rather than starting with assumptions about what was driving vaccination dropout at 9 months of age, the study used participatory tools, including vaccination journey mapping, photovoice, card sorting with heads of household and co-design workshops, to surface lived experiences.
Participatory tools revealed how small breakdowns accumulate, beginning in early infancy: a lost vaccination card, an unanswered question about side effects, a wasted trip because the clinic would not open a vaccine vial for only one or two children. Ideation workshops brought families, health workers and officials together to prioritize solutions based on feasibility and potential for impact. Next, ideas were stress-tested against real constraints like staffing and supply rules.
Crucially, communities are solution designers.
From insight to action: solutions shaped by context
The result was not a single intervention, but a package of complementary community-based solutions tailored to each context.
In Kaduna, participants prioritized an enhanced routine immunization and supervision checklist to improve how vaccination data is recorded and reconciled at the health facility, paired with clear, compassionate messaging from trusted local figures and community-based door-to-door reminders focused explicitly on the 9-month visit.
In Enugu, communities emphasized institutional accountability: improved facility-level tracking of children due for 9-month vaccines and a locally endorsed by-law requiring immunization verification for early education enrollment, designed with catch-up provisions to avoid punishment.
These solutions strengthen the interface between the community and the system to support continued motivation and intent in a setting where perseverance in the face of systemic barriers like restrictive vial size practices or stockouts is key. Across both states, solutions were tailored to restore urgency, rebuild reminders and ensure that when caregivers arrive, vaccination happens.
Why this matters beyond Nigeria
Fatima’s experience illustrates a broader lesson for late infancy immunization beyond any one country. Dropout at 9 months is not simply about awareness or knowledge, as it can be in early infancy, but is a predictable outcome of long gaps, weakened cues, shifting risk perceptions and fragile service reliability.
The research has already done the hard work to diagnose structural barriers, co-create solutions and test feasibility with communities and governments. What’s needed now is investment to implement and adapt these solutions at scale. When caregivers decide to do the right thing, the system must be ready to meet them there.