Community-based intervention to reach the last mile of childhood vaccination coverage in Burera district, Rwanda: a mixed method study

BACKGROUND: Vaccination remains one of the most cost-effective interventions for reducing childhood morbidity and mortality from vaccine-preventable diseases. Despite global progress, vaccination coverage has recently declined, particularly in low- and middle-income countries (LMIC). In Rwanda, national childhood vaccination coverage is at 95%, yet gaps persist in reaching last-mile and hard-to-reach populations. Community Health Workers (CHWs) play a critical role in promoting and delivering vaccination services at the community level. However, evidence on their specific contributions, particularly in rural settings such as Burera District in Northern Rwanda, remains limited. This study aimed to (1) describe CHW-reported and perceived factors influencing their involvement in promoting childhood vaccination, (2) describe self-reported CHW roles in vaccination activities among children under five, and (3) explore caregivers' perspectives on CHWs' involvement in childhood vaccination. METHODS: A mixed-methods study design was employed, combining a quantitative survey of 345 CHWs with individual interviews from 5 children's caregivers who benefited from community-based vaccination interventions conducted across 5 health centers in Burera District. Quantitative data were collected using structured questionnaires in REDCap and analyzed descriptively using STATA version 18. Qualitative data were analyzed using thematic analysis. RESULTS: Most CHWs were female (67.5%), married (98.8%), had primary-level education (86.1%), and were engaged in farming (98.6%). Nearly all CHWs had received vaccination-related training (94.5%) and considered children under-5 years of age vaccination very important (98.3%). Over half reported facilitating vaccination activities twice per month, and 93.9% were involved in community mobilization and campaign planning. Key activities included referring children to health facilities (58.0%) and conducting home-based vaccination outreach (42.0%). Caregivers highlighted CHWs' roles in health education, appointment reminders, and home-based services, emphasizing strong trust and their function as links between communities and the formal health system. Identified challenges included logistical constraints, the need for more consistent training and communication support. More than half of CHWs recommended strengthening structured community awareness, intervention and provision of monetary incentives for improving vaccination service delivery and community engagement. CONCLUSION: The perceived roles and self-reported practices showed that CHWs play a central role in sustaining high childhood vaccination coverage in rural Rwanda by improving access, awareness, and service delivery. Continued investment in CHW training, supervision, and logistical support is essential to sustain gains and achieve universal vaccination coverage by 2030.