Social Marketing to Enhance Community Empowerment and Ownership for a Successful Implementation of the "Big Catch-Up" in Togo in 2025: A Mixed Method Study

This mixed-method study demonstrates that a social marketing approach grounded in the 4Ps framework significantly increased immunization coverage and community engagement during Togo's 2025 "Big Catch-Up" initiative, though long-term success depends on institutionalizing community structures with domestic funding.

The Gist

Imagine Togo's vaccination system as a giant, well-oiled machine that suddenly jammed during the COVID-19 pandemic. Suddenly, thousands of children were left in the dark, missing their "shield" against dangerous diseases like measles and polio. By the end of 2023, nearly 70,000 children in Togo had received zero doses of vaccines, and another 25,000 were only partially protected.

To fix this, Togo launched a massive rescue mission in 2025 called the "Big Catch-Up." But they didn't just shout louder or hand out more flyers. They used a clever strategy called Social Marketing, which is like treating health not just as a medical service, but as a product that people actually want to buy.

Here is the story of how they turned the tide, explained simply.

The Problem: The "Lost" Children

Think of the pandemic as a thick fog that rolled over Togo. In that fog, families forgot about or couldn't reach the health clinics. The "Zero-Dose" children were like ships lost at sea, invisible to the lighthouse keepers (the health workers). The government knew they needed a new map and a new compass to find them.

The Solution: The "4-Point Compass" (The 4Ps)

The team decided to use a marketing playbook usually reserved for selling sneakers or soda, but applied it to vaccines. They called it the 4Ps:

1. Product (The Vaccine): They made sure the vaccine was the right "product." It wasn't just a shot; it was a promise of safety for your child.
2. Price (The Cost): The financial cost was free, but the "price" was often fear, rumors, or the hassle of traveling far. They worked to lower this "price" by bringing the vaccine closer to people's homes and calming their fears.
3. Place (Where to get it): Instead of waiting for people to come to the clinic, they turned the neighborhood into a clinic. They set up vaccination stations under trees, in village squares, and even inside homes.
4. Promotion (The Message): This was the big one. They didn't just use doctors to talk; they used the people the community already trusted: religious leaders, village chiefs, and local influencers.

The Secret Weapon: The "Village Watchdogs" (CSVs)

The most creative part of the plan was creating Vaccination Monitoring Committees (CSVs).

Imagine a neighborhood where the local leaders, the shop owners, and the respected elders form a team. Their job? To make sure no child is left behind.

• The Analogy: Think of them as the "neighborhood watch" for health. Instead of watching for burglars, they watched for unvaccinated kids.
• How it worked: These committees were made of locals. Because they were neighbors, not strangers in white coats, parents trusted them. If a mother was scared of a side effect, her neighbor on the committee could explain it in a way she understood.
• The Result: They established 157 of these teams, covering every priority area. They acted as a feedback loop, telling the government, "Hey, the clinic is too far," or "The staff is rude," and the government fixed it immediately.

The Magic of "Gamification"

To keep everyone motivated, they turned the mission into a friendly competition.

• The Analogy: Imagine a video game where districts earn "badges" and "trophies" for vaccinating the most kids.
• The Effect: When a district did well, they got a trophy and public praise. This made the village chiefs and health workers feel like heroes. It shifted the mood from "this is a boring job" to "this is a mission we can win."

The Results: A Miracle Turnaround

The numbers tell a story of a dramatic rescue:

• Before: In the first few months, only 1% of the target children were getting their first pentavalent vaccine (Penta1).
• After: By the end of the year, that number skyrocketed to 64%.
• The Speed: It's like a car going from a crawl to highway speed in just five months.
• Global Standing: Togo didn't just fix its own problem; it became the 3rd best country in all of Africa at catching up on these vaccines.

Why It Worked (The "Secret Sauce")

The study found that the magic wasn't just in the vaccines; it was in the trust.

• Religious Leaders: Pastors and Imams started checking vaccination records in their churches and mosques. If a child wasn't vaccinated, the leader would gently guide the family to a health worker.
• Home Visits: Health workers didn't wait; they knocked on doors. They explained the benefits right there in the living room, turning fear into confidence.
• Listening: The community felt heard. When they complained about long lines or cold vaccines, the system listened and fixed it.

The Catch: The "Battery" Problem

There is one big warning in the story. The battery that powered this success was mostly external funding (money from UNICEF and partners).

• The Metaphor: They built a beautiful, high-speed train, but they need to make sure the country can afford to buy the fuel to keep it running forever.
• The Challenge: The study warns that if the outside money stops, these "Village Watchdog" teams might stop working. To make this last, the government needs to take over the funding and make these community teams a permanent part of the health system.

The Bottom Line

Togo proved that when you treat a community like a partner rather than a patient, miracles happen. By using the tools of marketing, the power of local trust, and a little bit of friendly competition, they pulled thousands of children out of the "fog" of the pandemic and gave them their shield against disease.

The lesson for the world: You can't just force people to be healthy. You have to meet them where they are, listen to them, and make them the heroes of their own story.

Technical Summary

1. Problem Statement

The COVID-19 pandemic caused a severe disruption in routine immunization services in Togo, leading to a significant "immunity gap." By the end of 2023, Togo reported 69,672 "zero-dose" children (those who received no vaccines) and 24,846 "under-vaccinated" children (those who missed doses). Despite global efforts like the WHO/UNICEF "Big Catch-Up" (BCU) initiative launched in 2023 to recover pre-pandemic coverage levels, Togo faced specific structural weaknesses:

• Inadequate monitoring of zero-dose children.
• Low community involvement and persistent vaccine hesitancy.
• Significant geographical disparities in coverage, with some regions falling below 70% for key antigens.
• A lack of scientific literature on effective social marketing approaches specifically for post-pandemic immunization recovery in West Africa.

2. Methodology

The study employed a convergent mixed-methods design (quantitative and qualitative) guided by the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance).

• Study Setting & Population:

  • Location: 17 priority health districts across four regions (Grand Lomé, Maritime, Plateaux, Kara), representing >70% of the country's zero-dose and under-vaccinated children.
  • Target: 69,672 zero-dose and 24,846 under-vaccinated children (aged 0–59 months).
  • Timeline: Baseline (Jan–June 2025) vs. Intervention/Acceleration (Aug–Dec 2025). Data collection occurred in Jan 2026.

• Intervention (Social Marketing Approach):
  The intervention utilized a comprehensive 4Ps Social Marketing Framework:

  1. Product: Ensuring vaccine availability and addressing supply-side barriers.
  2. Price: Reducing non-monetary costs (e.g., time, travel) and addressing psychological barriers (fear/hesitancy).
  3. Place: Increasing accessibility through home visits and mobile vaccination sites.
  4. Promotion: Community engagement, codesign, and behavior change communication.
  • Key Mechanism: Establishment of 157 Vaccination Monitoring Committees (CSV) comprising community leaders, health workers, and chiefs to drive local accountability.

• Data Collection & Analysis:

  • Quantitative: Administrative data from DHIS2, facility registers, and BCU reporting forms. Analysis included Chi-squared tests for linear trends to compare coverage before and after intervention. Togo's performance was benchmarked against 23 other African BCU countries.
  • Qualitative: In-depth interviews (IDIs) with 10 key informants (health officials, CSV members, community leaders) and document reviews. Data was analyzed using thematic content analysis (hybrid coding).
  • Ethics: Approved by the University of Lomé Institutional Review Board.

3. Key Contributions

• Evidence of Effectiveness: Provides robust empirical evidence that a social marketing approach grounded in the 4Ps can rapidly reverse immunization declines in a post-pandemic West African context.
• Community Ownership Model: Demonstrates the efficacy of codesigning interventions with communities (via CSVs) rather than top-down implementation, fostering cultural appropriateness and local accountability.
• Operational Innovation: Introduces a "simultaneous approach" where awareness raising, case finding, and vaccination occur in the same visit (e.g., under trees or at chiefs' homes), reducing drop-out rates.
• Regional Benchmarking: Offers a comparative analysis placing Togo's performance within the broader African BCU landscape, highlighting rapid acceleration strategies.

4. Key Results

Quantitative Outcomes:

• Dramatic Coverage Increases:
  • Penta1: Increased from 1% (Q1) to 64% (Q4).
  • Penta3: Increased from 1% (Q1) to 45% (Q4).
  • MR1: Increased from 4% (Q1) to 50% (Q4).
  • MR2: Increased from 6% (Q1) to 49% (Q4).
  • Statistical Significance: All increases were statistically significant (p<0.001).
• Acceleration: The August–December intervention period accounted for 94% of the total annual gain in Penta1 coverage.
• Regional Ranking: Togo ranked 3rd out of 24 African countries for Penta1 progress and 5th for Penta3 progress.

Qualitative Outcomes:

• Acceptability: High community acceptance. The CSVs were praised as culturally appropriate. Religious and traditional leaders (pastors, imams, Vodou priests) played a critical role in mobilizing families and reducing hesitancy.
• Feasibility: The intervention was operationally feasible but resource-intensive. A cascading training model successfully trained 1,917 actors (vaccinators, CHWs, community relays).
• Barriers: Identified challenges included geographical inaccessibility during rainy seasons, insufficient human resources (CHWs), and concerns regarding long-term sustainability without domestic funding.
• Facilitators: Strong government-UNICEF collaboration, codesign methodology, and gamification/recognition ceremonies for high-performing districts.

5. Significance and Implications

• Policy Impact: The study validates that social marketing, when integrated with community structures like CSVs, is a viable strategy for closing the immunization gap. It suggests that institutionalizing these community committees with domestic funding is critical for sustainability.
• Global Health Relevance: The Togolese model offers a transferable blueprint for other African nations facing similar post-pandemic recovery challenges. It highlights that rapid gains are possible through strategic intensification and community ownership.
• Future Directions: The authors emphasize that while the "Big Catch-Up" achieved rapid results, long-term success depends on:
  1. Institutionalizing community mechanisms (CSVs) into the routine health system.
  2. Securing sustainable domestic financing.
  3. Strengthening health information systems for better data quality.
  4. Continuing to address structural barriers (infrastructure, workforce).

Conclusion: The study concludes that social marketing effectively enhanced community adherence and immunization coverage in Togo. However, to achieve the Immunization Agenda 2030 goals, these gains must be sustained through political will, financial commitment, and the continued empowerment of community-led health structures.