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Addressing demAnd side issues

Health Managers Modules for Immunization

Information in this module compiled by NIPI-UNOPS and NCHRC-NIHFW, Delhi IndiaFor Block Child Health Managers and Block Program Managers, under NRHMDraft version January 2012

Module 5: Addressing demand side issues in Immunization | 3

The Universal Immunization Program, launched in 1985 for reducing deaths and disabilities due to vaccine preventable diseases in the country, has received a special impetus through the National Rural Health Mission (NRHM). The strengthening support provided by NRHM includes funds, resources, strategic guidelines and contractual manpower for program management. Since 2005, when the NRHM came into effect, there has been an increasing trend in Immunization coverage and quality.

Child Health managers introduced to manage and oversee child health and immunization in select districts of low performing states, as well as other health managers from non-medical background introduced through the NRHM, was found to have an increasing role in the Immunization Program. However they often came with no prior knowledge, experience or skills related to management of the Immunization program. Their roles and therefore their requirement in the program were identified as being a mixture of technical, supervisory and managerial. This set of modules covers many of these aspects, and have been developed for self as well as collective learning by program managers and supervisors.

The modules have been compiled from existing literature related to the Immunization program and health management available in India with the Ministry of Health and Family Welfare as well as with UNICEF, WHO, USAID and PATH. The materials have been adapted to meet the requirements at the primary levels of health program management in the country, particularly at the sector, block and district levels.

The National Child Health Resource Center (NCHRC) at the National institute of Health and Family Welfare (NIHFW) has worked closely with national trainers in Immunization at the NIHFW and the Immunization officer of United Nations Office for Project Services, Norway India Partnership Initiative (UNOPS-NIPI) in developing these modules. The pilot testing of these modules has been conducted in Orissa, Bihar and Rajasthan involving the district, block and sub block level managers and supervisors along with select state level trainers, and their feedback has been incorporated. UNOPS-NIPI has been instrumental in identifying the need for improving program management at implementation levels as an important step to achieve enhanced program coverage and quality, and have also provided the required support for the development of these modules.

We hope that this set of module will prove to be useful in enhancing the capacity of managers and supervisors at implementation levels for improving quality and coverage of lmmunization.

Dr. Kaliprasad Pappu Prof. Jayant K. DasDirector, Director,UNOPS-NIPI LFA National Institute of Health and Family welfareNew Delhi New Delhi

Foreword


Table of Contents Abbreviation .......................................................................................................................................................................7

I. Introduction ..................................................................................................................................................................... 11

II. Provide quality consistent services ......................................................................................................................... 13

III. Arrange for visibility and awareness of services ................................................................................................. 15

IV. Communicate with and involve the community ............................................................................................... 17

V ABC of communication ................................................................................................................................................ 19

a) Advocacy with leaders and influencers ................................................................................................................. 19

b) Behavior change communication ........................................................................................................................... 21

c) Communication through mass media, folk media and interpersonal means ......................................... 24

VI. Effective social mobilization ...................................................................................................................................... 29

VII. Addressing issues of drop out .................................................................................................................................. 31

VIII. Tools for better communication ............................................................................................................................... 33

IX. Making a comprehensive communication plan ................................................................................................. 37

Final Assessment ............................................................................................................................................................ 39

References ........................................................................................................................................................................ 43

Facilitators Guide ........................................................................................................................................................... 45


Abbreviations

Abbreviation Extended form

ANC Antenatal checkup

ASHA Accredited Social Health Activist

AWW Anganwadi worker

BDO Block Development Office/Officer

DPT Diphtheria Pertussis Tetanus Vaccine

EPI Expanded Program on Immunization

FAQ Frequently Asked Question

FRU First Referral Unit

ICDS Integrated Childhood Development Services

IPC Interpersonal Communication

MCP Mother and Child Protection Card

NRHM National Rural Health Mission

PHC Primary Health Center

PIP Program Implementation Plan

PNC Postnatal checkup

TT Tetanus Toxoid Vaccine

UNOPS-NIPI United Nations Office for Project Services – Norway India Partnership Initiative

VHSC Village Health and Sanitation Committee

WHO World Health Organization


Objectives By the end of the module, the health managers will be able to

• Understand the need for and methods to address demand side issues to improve immunization program

• Effectively utilize communication materials and communication methods to improve immunization coverage

• Be effective advocates for the immunization program and get involved in using various aspects of communication to improve the demand of vaccination services.

• Make an effective communication plan for their areas to improve immunization.

Contents:I. Introduction

II. Provide quality consistent services

III. Arrange for visibility and awareness of services

IV. Communicate with and involve the community

V ABC of communication

a) Advocacy with leaders and influencers

b) Behavior change communication

c) Communication through mass media, folk media and interpersonal means

VI. Effective social mobilization

VII. Addressing issues of drop out

VIII. Tools for better communication

IX. Making a comprehensive communication plan

Health managers’ modules for ImmunizationModule 5: Addressing demand side issues


The graph above is from the Coverage Evaluation Survey undertaken in 2009 and looks at the reasons for partial or no immunization as given by guardians and beneficiaries. It seems evident from the graph that for the immunization program to be successful, the program manager would have to address issues both on the supply and demand issues. However the graph also shows that the demand side issues are more critical reasons for partial and no vaccination.

What do you need to do as a manager to address these demand side issues? Look at each of these issues and think of means and methods to address them. Almost a quarter of these persons do not feel the need to receive vaccines and a similar proportion do not know about vaccines at all! Many others have problems with time, place and side effects related to vaccination.

In this module we are going to learn how a manager at a block or district level can help in developing an effective plan to improve demand for immunization services. We would also see how these plans can be effectively implemented to bring down the rates of drop out and left out beneficiaries.

; Group discussion: divide participants into three groups as given in the figure. Try to find out issues as to why they remain in their particular groups. Discuss what can be done to ensure all beneficiaries in the community become fully vaccinated by the time they reach 1 year of age.

I. Introduction

Module 5: Addressing demand side issues in Immunization | 13II: Provide quality consistent services

Do you have a favorite market or a shop that you frequent? Why do you go there to buy your goods most of the time? How often have you found it closed when you needed something urgently? Was there any time you wanted a particular material in the shop and you could not get it?

What do you think is the reason behind a successful venture that has created a lot of public demand?

Can you think of the services that you require that you are pleased with and would use the same service provider again?

Do you think if immunization services become regular, reliable, the behavior of the service providers are pleasant and the service quality is good, an increased demand will soon follow?

Think of a new-born child’s parents in your work area, if possible think of the last house in a distant village, and then try to answer these questions:

• Do they know the need to vaccinate the child?

• Do they know where to get their child vaccinated?

• Do they know when the services are available?

• Is the service provided near where they live?

• What would be the time they would have to spend to avail the service?

• Do they know that vaccination services are free of cost?

• Would they be satisfied with the service they got?

• Would they know when to come again?

• Would they want to come again?

As you find the answer to these questions, you will realize that the first step to increasing demand for vaccination services is to ensure quality and reliable services are available consistently in the village areas and that the people are both aware of these services and are satisfied with them. As a manager your work to ensure health workers absenteeism’s are minimized, that they are trained well and pleasant in their behavior, all vaccines and logistics are consistently and timely available, mobilizers are active in informing parents and guardians and sessions are not cancelled will go a long way in ensuring a steady demand for vaccines.

Module 5: Addressing demand side issues in Immunization | 15III: Arrange for visibility and awareness of services

Can you think of any event or activity you have come to know through a good communication method? It could be the Polio Sunday dates that are announced with a flurry of yellow banners and posters in the towns and villages or the recent bollywood movie that has a large hoarding at the most prominent cinema hall, as well as a small advertisement for the newly released movie on all the daily papers. Do you think they have been effective? If you had a small child would the pulse polio banners remind you to get a vaccine dose for your child? Would you look forward to seeing the movie once you see the cinema billboards?

Arranging for visibility and awareness of immunization and outreach health services to the general public and particularly to beneficiaries is the initial and the perhaps the easiest step of communication. Most of the materials made available to districts and blocks would have been developed at national and state levels after careful planning, designing and testing.

Many activities also have fixed color schemes, slogans and logos which become easily identifiable; this is also called “brand imaging”. The Polio eradication campaign, for example, has the color yellow, the slogan “do boondh zindagi ki” (two drops of life) and the logo of two drops which can be instantly recognized. Likewise, for Routine Immunization, designs for banners and posters have been developed at the national level which the states may use. Some of the specimens are given here.

As a manager how would you plan for the effective use of communication material? The materials generally available to you may be in the form of posters, wall paintings, tin boards, hoardings, banners, stickers, fliers or handouts and sometimes even audio jingles and video snippets. You would have to plan when and how to use them.

It would be wise to read the content and see the pictures of the material available to you before arranging for their placements. You have to be sure that what has been written or shown is consistent with the guidelines of the program. Banners and posters in the local language should always be preferred. Managers at the state level would usually have ensured this.

In the posters above, one stresses on birth dose vaccination following institutional deliveries and the other encourages the

16 | Health managers’ modules on Immunization

beneficiaries to ensure the child completes the vaccine doses as per immunization schedule. Where would you plan to use these posters? If banners have to be put up at outreach sites banners in which of the two designs would you prefer to use? Can you make a plan like the one below?

Plan for utilization of Communication material for Routine Immunization in Block XYZ

Tyep of Material Ideal places/sites of placement

Numbers needed

Person responsible for use

Person verifying its proper placement and use

Birth dose hoarding

Near District and FRU hospital campus

1 to 3 Local contractor/advertizing agent

Block manager/Medical officer

Birth dose poster/banner

Near labor room, ANC and PNC wards, corridoors

10 to 15 Staff labour room/hospital

Hospital manager/administrator

Rl hoarding At any major intersection in town, near hospital campus

1 to 3 Local contractor/advertizing agent


Rl site poster (large)/tin plate

At all fixed sites providing vaccines

15 to 20 Staff vaccination clinic/agent


Rl site poster (small)

At prominent locations and fixed vaccination sites

20 to 30 Local contractor/advertizing agent/hospital staff


Rl site banner (flex)

All outreach sites for vaccination

50 to 80 Health workers Health supervisors

Rl FAQ handouts To beneficiaries and community influencers

1000 to 5000

Health workers/supervisors

Health supervisors

Rl site Banner (long)

For vaccine delivery vehicles and fixed sites

20 to 40 Alternate vaccine delivery persons/hospital staff


Module 5: Addressing demand side issues in Immunization | 17IV: Communicate with and involve the community

It is important to involve the community if demand for services is to be properly generated. The involvement should not begin once the services are made available but much earlier beginning from the planning phase itself. Following this, involving the community in providing and evaluating health services will also go a long way in assuring the community about the quality of services and increasing the demand on a long way. The village health and sanitation committees have been created with all these aspects of community involvement in mind.

Below are some examples of how the village health and sanitation committee can help in planning, implementation, and monitoring.

Planning: Health staff should consult the VHSC members about service locations and timing to ensure a convenient service. Options include the following:

• Having immunization available one evening a week or one Saturday or Sunday afternoon a month, to ensure that working parents are able to bring their children for immunization.

• Moving vaccination hours from early mornings to afternoons in areas where mothers are busy in the fields or selling at the market in the morning.

Implementation: VHSCs can assist with

• Arranging a clean outreach site (school, community meeting room, etc.);

• Informing community members when the health worker arrives at the outreach site;

• Registering patients, crowd control, and making waiting areas more comfortable (by providing shade and organizing space and seating);

• Health education — disseminating appropriate messages;

• Motivating fellow community members to use the immunization and primary health care (PHC) services;

• Transporting vaccines and health workers;

• Arranging home visits when children are behind schedule, to explain immunization and to motivate caregivers.

Evaluation: When health staff give information and feedback to VHSC and the communities at large about coverage and disease outbreaks, and solicit community input for solving problems, community members themselves can contribute to identifying issues and defining solutions.


The manager’s relationship with the VHSC and communityWhen discussing community participation, “increasing demand“ is often used as a general description, but this term can give the impression that lack of motivation or desire for immunization is the reason why children are not getting vaccinated. In reality, mothers are often very willing to have their children vaccinated: if the services are available at a convenient time and place, and service delivery is of good quality, the mother will be aware of what she needs to do to ensure that her child is vaccinated. The issue is more complex than just simply “demand“ and involves issues of advocacy, mobilization, and communication (e.g. information to the community; building awareness of services and what the health centre can and should provide; mobilizing resources; establishing a rapport with the community for planning and implementation; and educating mothers on the vaccination schedule for their children). A manager should therefore include some of the elements listed below into the programme, in order to ensure that there are strong links to the community.


5 a. Advocacy

5 b. Behavior change communication

5 c. Communication through middle and mass media

5a. Advocacy with leaders, influencers, organizations and groups

Group B can discuss and present on the elements of making a supervisory plan based on the outline below.

Advocacy might be best characterized as any effort to influence policy and decision makers, to fight for social change, to transform public perceptions and attitudes, to modify behaviors, or to mobilize human and other material resources. In your efforts to improve immunization and child health, advocacy might encompass all these definitions in one form or another.

Many advocacy activities are common to almost every job in health and public services: meeting with a community leader, meeting with your boss, talking to parents and children, training health workers, writing a letter to the concerned officers at higher offices of NRHM and your state health department, or discussing future partnerships with a other immunization partner organizations like Unicef, WHO, UNOPS NIPI, Path, Care and BMG foundation.

The manager as an advocate!

As a manager for child health activities at block and district level, YOU are the best advocate for the immunization program. Ownership of the program begins with YOU and your endeavor should be to build up co-owners and partners for immunization and child health programs in your areas.

Does advocacy work?Yes! There are many examples of successful advocacy efforts—some of which have shown dramatic results. Remember that all advocacy efforts require careful planning, commitment, resources, and energy. When you are able and willing to sustain your advocacy efforts over the long term, meaningful change can occur.

Steps in effective advocacy:

V: ABCs of communication

Characteristics of an Advocate’• Researches the issue.

• Believes in the issue.

• Gives real-life examples.

• Plans for small changes.

• Is passionate and persistent.

• Takes advantages of opportunities.

• Is a good negotiator.

• Is hard to intimidate.

• Stays focused on the issues.


Step 1: Gathering information:

Gather local facts and figures related to immunization like coverage, drop outs and incidence of diseases.

Maintain a list of all organizations interested in immunization, health, or child issues, and stay informed of their work; they might become powerful allies for your effort. Some examples are below:

• The ICDS scheme has immunization as one of its core activities so they can become your natural ally.

• The block development office could also be interested in child registration, vital statistics and general administration, see how they can help you.

• The panchayati raj institutes and other local representatives may be interested in ensuring that their constituents are in good health.

• The village health and sanitations committees are important set-up that can play a key role in planning, implementation and evaluation of health activities.

• Some local self help groups and non government organizations may want to contribute to the society and could be interested in helping in immunization

• Faith based organizations and religious leaders have also know to have contributed to immunization programs

Gather information and list the key decision makers and influencers are in your area. They could be active social workers, religious leaders, elected representatives or even sometime a well known and respected local doctor or government official. These influencers can be used to counsel specific left out and drop out families.

Find out how they can actively support, and how they might positively or negatively impact immunization services through their decisions. Gather their contact information and summaries of their positions on health issues. See how they can be involved in immunization and child health programs.

Step 2: Building a plan and engaging allies for activity

Plan how you can best use the help of these organizations and persons who you have listed.

Prepare what you are going to say and present during the first meeting. Local facts and figures which you have gathered earlier can be used in an appropriate manner. Be specific in the help that you seek. Be sure to tell them how they are to benefit from this activity.

Sometimes an entire group can be addressed during a meeting, e.g. a monthly meeting of elected representatives in the BDO office where half an hour can be utilized for advocacy of health issues.

In some areas steering committees for immunization have been formed involving various potential allies at block level. In many blocks the Rogi kalian samitis have also been used to effectively ensure advocacy and community involvement.

Leave behind a simple, one-page outline of your request as a concrete reminder of your visit, and, if asked, provide additional information in a timely manner. Never misrepresent an issue. If you do not know the answer to a question, tell them so. They will respect your honesty and learn to trust you as a valid source of information on immunization issues.

Depending on your communication and program implementation issues a plan can be formulated to engage allies for program improvement.


Implementation/communication issue

Individual/agency whose helps is sought

What help is needed What results is expected

Site needed for holding immunization sessions

ICDS dept and Primary school dept

Allow for use of premises on vaccination days

Outreach sites determined at all ICDS centers and selected primary schools

Agency needed for alternate vaccine delivery

Block development officer

Help identify local persons who can spare time and vehicles to reach vaccines

Specific responsible persons with reliable and available vehicles determined for alternative vaccine delivery

Persons of a particular religious sect refusing vaccination

Local religious leader of this particular sect

To communicate to the followers the benefits of vaccination

Particular religious sect accepts vaccines

Hard to reach area needing special transport for reaching vaccines and vaccination team

Local leaders and active community members from this area

Provide boats and tractors 4 times a year and ensure communication for these special days throughout the area

Successful hard to reach vaccination efforts

Certain persons of the urban area refusing government supplied vaccines

Local practitioner Explain the need and quality of govt. vaccination program to his clients

Vaccines accepted by refusal families

Step 3: Measure the results

The results of your advocacy efforts should have been determined before hand by you as well as the allies you have engaged through your advocacy.

Once the activity is carried out as planned, the results can be determined.

Successful advocacy efforts will help you not only better the program but also keep the motivation of your teams and your allies.


Short case studies

Two nomadic communities have settled near two villages of a block for several years. Roshni and Meena are two ANMs who have both been assigned one each of these communities to provide outreach health services. Both of them have made their session micro plan to visit their areas once a month. One year after they have started visiting these areas, on an outreach session day, the health manager of the block visits both these areas as given in the micro plan. This is what he finds:

Roshni:

Roshni is not present in the area at 10 a.m. Most people are unaware of when she comes and where the session is held. Very few mothers know about vaccination and few can remember seeing her during the course of the year. Of the pregnant women and children interviewed only 1 pregnant woman has been vaccinated with a single shot of TT, that also in her husband’s village which is in another district. She has not got her second dose as yet. The manager calls up Roshni in her mobile and she tells him her location which is the house of the village headman of the main village adjoining the nomadic area. The manager finds her in the given location and she has arranged her session site there with banners, vaccines, chairs and table. She also arranges tea for the manager as soon as he arrives.


When asked about the vaccination status of the nomadic people Roshni complains that there is no ASHA or mobilizer for the area. She went there to the area where the nomadic population lived, the first two months to call them but they did not cooperate; they did not provide her a room, or table, or chair. As the village headman of the main village was of the same caste as her and provided all the arrangements, she set up her site at his house. The nomadic people do not come to her session site although she is regular and sincere. She feels that they are dirty and impolite and refuse vaccines.

Meena:

At 11.30 am, Meena is found working in the middle of the nomadic community’s area on a mat on a floor beneath a large tree. She is surrounded by women and children. She is seen given a DPT dose to a small infant and after the vaccination; she spends time telling the mother about the possible side effects, gives her some medicine and tells her the need to bring the child again the next month for the next dose of the vaccine. The mother smiles in acknowledgement and accepts the card as Meena again explains what has been written in the card and to bring the card again in the next visit.

During the manager’s interaction with Meena, he finds out that, like Roshni, she had problems in the initial months. However she did not feel they were impolite and dirty and felt that they just needed some help. An opportunity arrived when one of the women of the village went into complicated labour. Meena herself accompanied this woman to the hospital where she gave birth to a healthy baby girl. The infant was vaccinated in the hospital with the birth dose vaccines and later also continued the rest of the vaccines from Meena at her outreach site. Seeing this other villagers soon started coming to Meena for vaccination; a few even helped with the floor mat and mobilization. Soon all the nomadic population understood vaccines were good for them. They came timely for their vaccines and children and pregnant women completed their vaccine series.

; Discuss about Roshni and Meena’s behaviors and the outcome in their work

What is behavior change communication?

This is a strategy, which refers to the systematic attempt to modify/influence behavior, or practices and environmental factors related to that behavior, which indirectly or directly promote health, prevent illness or protect individuals from harm.

Whose behavior?

As a manager you would have to understand both the consequences of good and bad behavior on health outcomes and well as the target persons whose behavior needs to be modified.

Many experts believe the provider should be the major focus of behavior change efforts in immunization programs. The many roles of the provider and his or her influence on the immunization status of children are often overlooked. This influence is very strong. In fact, most parents will do what the health worker tells them, as far as immunization is concerned.

However, communication programs rarely pay adequate attention either to understanding provider behaviors or planning strategies to improve their practices.

Program managers also tend to assume that families are the sole or at least major targets of communication. While efforts to modify behavior of beneficiaries and community can certainly be of help, focusing on the health workers and mobilizers and their behavior as well as communication skills would actually bring better outcomes.


Immunization related behavior among health workers.

• Perform immunization tasks correctly, including those that ensure safe injections.

• Give mothers and other caretakers essential information on when to return and side effects.

• Schedule and organize services to make them convenient for parents. Be reliable with services.

• Treat families well on each visit and praise families whose children are fully immunized by one year of age.

• Understand the constraints and fears of beneficiaries in regard to immunization

• Help them and show through your actions that you are concerned about their health and well being

• Give requisite message clearly and consistently;

• Place and time of vaccination

• Basic side effects and their management

• When to come next

• Take vaccines timely and complete the series

Immunization related behaviors encouraged among caregivers, community and public leaders

Mothers and Other Primary Caretakers

• Bring children to immunization service delivery points at the ages recommended in the national schedule.

• Bring each child’s health or vaccination card to each health visit.

• Treat side effects as recommended.

• Seek tetanus toxoid immunizations for yourself (mothers and other women of childbearing age).

Fathers

• Bring children to immunization service delivery points yourself, or encourage their mother to do so.

• Provide mothers with money for transport or other expenses related to immunizing children.

• Political and Public Health Leaders

• Allocate sufficient financial and human resources to immunization services.

• Show personal support for immunization services.

; Facilitators guide: Role plays showing different types of behavior of health workers during their interaction with beneficiaries and care givers


Community Leaders

• Describe the benefits and safety of vaccinations to others in the community.

• Remind families when children need to receive the next dose(s) of vaccine.

• Encourage families to complete each child’s basic immunizations in their first year of life.

• Inform families when and where outreach services and supplemental immunization activities are taking place and about new vaccines or other improvements in the immunization program.

• Assist health facility staff in planning and monitoring services.

• Provide logistical support, e.g., by transporting vaccines, supplies, and staff.

A study in Burkina Faso in the early 1990s showed that mothers who had been exposed to a variety of interpersonal and media messages were more likely to know the requirements to complete vaccination schedule and know the dates for specific vaccines than mothers in the control group (Bhattacharyya et al. 1994).

A media project was credited for a significant change in knowledge about the immunization schedule in Ecuador in the late 1980s. The proportion of respondents with correct knowledge

5c. Communication through mass, folk media and interpersonal means

(i) Mass Media:

The access to mass media may not be readily available to a manager at the block or district level. Mangers at state and national levels would have contacted national television and radio studios and given them the requisites spots, jingles and communication materials for wide publicity. There are also television serials which promote immunization and other health activities.

However local newspaper reporters are readily available at district and block levels and are often quick to print any news regarding health events and disease outbreaks. The manager can ensure that these reports in local newspapers do not misrepresent any facts and do not lead to disruption of health services. Positive events like workshops, trainings, health festivals and fairs should receive local media coverage. Good relations with local media persons help in ensuring positive media coverage.

Below are some examples of how mass media has contributed significantly to health outcomes:


went from 65 percent in November 1985 to 91 percent in April 1987. During that period, measles immunization coverage among 12 month-olds increased from 15 percent to 35 percent (HEALTHCOM 1992).

Communication provided significant support to diphtheria immunization programs in Russia in the mid-1990s, following outbreaks after a significant drop in DTP coverage. After two months, various media were cited by one-third of Novgorod’s vaccinated population as one of the means through which they learned about the need for additional doses of diphtheria vaccine. In Voronezh, higher exposure to media messages correlated with higher coverage rates for the same communication intervention period (Porter et al. 2000).

In India, exposure to television and radio spots featuring a popular film celebrity influenced caregivers’ decision to go to vaccination booths during the polio immunization campaigns in 2003 (Waisbord 2003).

(ii) Folk media

Folk media is defined as “any form of endogenous communication system which by virtue of its origin from, and integration into a specific culture, serves as a channel for messages in a way and manner that requires the utilization of the values, symbols, institutions, and ethos of the host culture through its unique qualities and attributes.”

Folk media are often used for personal as well as group information sharing and discussion and draw their popularity from their entertaining nature. Types of folk media include storytelling, puppetry, proverbs, visual art, drama, role-play, concerts, gong beating, dirges, songs, drumming, and dancing.

Folk media are personal forms of entertainment and communication. This is important because behavioral changes are most easily brought about by personal interaction. These forms of art are a part of the way of life of a community and provide acceptable means of bringing development issues into the community in its own-terms. They are capable of reaching intimate social groups, thus making use of already established communication networks in the audience.

Another advantage of the traditional media is that they attract people who might not attend an educational meeting. With skill, new content might be added to the old forms which are already familiar and dear to the people. Finally, unlike mass media programs, produced for large and often diverse audience, the folk forms can use familiar dialects for the most intimate and local communication at the village level.

Where needed, especially for resistant groups, folk media can be an effective means of communication to increase acceptance to outreach health services. Certain activities like drum beating as a reminder of session days and puppet shows showing the importance of vaccination can be undertaken.

(iii) Interpersonal Communication

Interpersonal communication (IPC) is

• A direct face to face communication between two persons or groups.

• It directly relates to people’s emotions, needs and feelings.


• At a one-to-one or one-to-few level where people feel more comfortable to voice their genuine needs, fears and questions

• A unique method to address individual issues which may have further effects on the community as a whole.

• An ideal forum for personal problem solving and diffusing underlying suspicions and fears.

• Is uniquely based on trust and relationship building between the two sides involved in the interpersonal communication process.

• Is however important to ensure that IPC is a two-way conversation and a good deal of listening and probing is used as well as telling and advising.

; Do a group exercise on practicing two way conversation using 4-6 persons. Each participant should be given a similar piece of paper. Give them a series of instructions to fold, tear and cut the paper in different manners. The participants should be all facing the wall so they cannot see each other. They should not be encouraged to request for repeating or explaining the instructions. You will see that at the end of the exercise each participant’s piece of paper will look different. Following this you will have to explain that just by giving the instructions, one should not assume everything has been correctly understood. Unless a two-way conversation takes place, communication is never complete.

For the promotion of immunization and other outreach health services, there are several opportunities for effective use of IPC both as one-to-one and one-to-few methods. The diagram following illustrates these opportunities.

One-to-one• Health supervisor with health worker during

session site and field visits

• Health worker with ASHA / ICDS worker

• Health worker with VHSC member/ influencer/mother/guardian/beneficiary

• ASHA/ICDS worker with beneficiary/ mother

• Two mothers/ beneficiaries

• Influencer/ VHSC member with beneficiary/ mother/guardian

One -to-few• Sector Supervisor to group of health

workers during weekly/ monthly meetings

• Health worker to group of ASHA and ICDS workers of the Health subcenter area

• Health worker with group of mother and village women (mahila mandal)

• Health worker with VHSC/ village influencers

• ASHA/AWW with village women and mothers


A simple procedure to follow during inter personal communication is what is known as the GATHER technique (G-A-T-H-E-R as in the table that follows).

Greet

Ask

Tell

Help

Explain

Return

•••

•••

•••

•••

•••

•••

; Think of some situations where you might find IPC effective.

; List some of the occasions where field level workers and mobilizers can use IPC to reduce drop outs.

; Demonstrate the GATHER process for the introduction of Hepatitis B in your area where as a manager you are talking with a group of health workers during a monthly block meeting.

Module 5: Addressing demand side issues in Immunization | 29VI: Social Mobilization

Good communication should lead to effective social mobilization of beneficiaries to accept vaccines and other outreach health services.

For the reproductive and child health programs to be successful, it is not just the initiation of vaccination that is important but also the completion of the entire series of services along the continuum of care. The major responsibilities of the ASHA workers is to ensure among beneficiaries both an awareness and utilization of these services.

For an ASHA to be effective three things are essential:

a) The ASHA herself to know about the health services needed and available for the beneficiaries at different periods of time.

b) Good communication skills and commitment towards health outcomes of her community at large and more specifically the mothers and children.

c) User friendly and effective tools for the ASHA to make her working orderly, organized and efficient.

As a manager it would be your responsibility to equip the ASHA to make her effective.

How could you, as a manager ensure that the ASHAs of your area deliver the outputs required through the Immunization program? Outputs, such as requisite TT doses to pregnant women, birth dose vaccination, full immunization by one year of age etc., could be tabulated ASHA wise and then closely monitored by you!

Below are some of the actions recommended to you as a manager to help the ASHAs reach these goals:

• Ensure ASHAs have complete knowledge of vaccines and the immunization schedule, including the minor side effects following vaccination and their management. The Medical Officers, health workers and supervisors can help out in the capacity building of ASHAs through training and continued hand-holding.

• Help ASHAs building good relationships with village influencers and families with mothers and small children though mentoring in behavior change communication by health workers and supervisors. Increasing the involvement of ASHAs in mobilization and bridging the community and health service providers and improving their interpersonal communication skills would also help.

• Familiarize ASHAs in the use of tracking registers, counterfoils, due-lists (and other tools) and sometimes even mobile phones as reminders for dates of vaccination of beneficiaries.

• Timely and correct payment of incentives due to ASHAs would by far be the best motivation for her to perform well; as a manager you would have to follow this up closely!

In areas where ASHAs have not been selected or are not available, The NRHM PIP has provided for the hiring of mobilizers. These should be active persons from the locality preferably ladies who can help the health workers in mobilizing the women and children for vaccination.

Module 5: Addressing demand side issues in Immunization | 31VII: Addressing issues of drop out through communication

7 a. Preventing drop-outs through good provider behavior and reliable servicesMany more children drop out of the immunization series after receiving one or more vaccinations than are left out entirely. WHO considers a dropout rate of more than 10 percent a problem. Any level of dropout indicates a problem, however. Dropout problems may involve access issues but are usually a sign that something else is going wrong. These are families who were motivated and successful in starting the series.

Common reasons for dropping out can often be linked with the behaviour of the health provider:

Demeaning or Punishing Experience for the Parent:

Many providers treat families badly or even abuse them. Parents often report that health workers yell, criticize them, and discourage questions.

Unfortunately this is one of the most commonly cited barriers to immunization. Combined with the frustration of hot days, long lines, late openings, or even cancelled services on announced days, ill-treatment can discourage return visits. Poor vaccination techniques can also cause anxiety in parents.

Lack of Information:

Parents may not be counseled on when to bring the child back for the next vaccination. Many health workers do not fill out immunization cards, either because they’re too busy or because they think parents can’t read them. Often health workers don’t know how important it is to make sure parents know when to return or to ask if they understand.

Poor Synchronization of Supply and Demand:

The delivery system loses credibility if it does not provide services as advertised. Failure of scheduled services to materialize, late openings, long lines, and shortages of supplies are common complaints.

Concern about Side Effects:

Many children have minor side effects (fever, temporary redness). Parents should be told this is common, what to do about it, and not to worry. The nature of each vaccination experience clearly affects whether a child will or will not be brought back.

Besides giving the injection, the ideal provider practices are to:

• Emphasize the importance of vaccination

• Fill out the health card and explain it

• Explain where and when to return for a next immunization, and how many in the series remain

• Explain common side effects and what to do about them

• Respond to doubts and fears

• Respond to questions

• Congratulate the parent.

These behaviors also need to be emphasized in a supportive supervision visit.


7 b. Addressing drop-outs through effective tracking and counseling mechanismsA study conducted to understand why successive doses of vaccines are not taken revealed the following:

• Mothers and guardians do not know if and when they have to come for the next visit.

• They do not understand the need for many doses and vaccination is not a priority for them

• Pregnant women and infants move from one village to another and those who have initiated the vaccination in one village sometimes do not continue the series in the next.

• Routine side effects like fever and swelling are not explained by health workers and guardians become reluctant to take the infants for vaccination again.

Apart from the health workers and vaccination service providers, the mobilizers such and ASHA, ICDS workers and other community volunteers can play an important role in drop-out reduction.

Managers, health supervisors and workers can play an important role in equipping the mobilizers to reduce drop outs.

The following actions are required of mobilizers to prevent and address issues of drop out.

a) Maintain a complete list of beneficiaries of their areas and update it regularly

b) Maintain a tracking register and understand how to fill it.

c) Know the schedule for each service along the antenatal, natal, post natal, infancy and childhood timeline.

d) Identify any drop-outs from these registers and make an extra effort to include them in the next outreach session.

e) For habitual drop-outs find the reasons for their non-acceptance. Counsel them. Take the help of other mothers, influencers and family members if needed. Address their concerns and fears.

f ) Following each session make complete due-list with the health worker for the next session. Ensure all guardian/mothers of these beneficiaries are reminded the day before and on the day of the session to get their due-dose or due-service.

g) Remember to look out for visitors from other villages, encourage them to get their vaccines in the village they are currently in. Do not turn them away for lack of vaccination card.

h) Visit beneficiaries after the vaccination day and see if they have any side effects. Counsel them and help them manage small problems. Help them to visit a health worker or medical officer if the adverse effects are serious.

Occasionally health workers, supervisors and community influencers may need to counsel guardians of drop out beneficiaries.

In some areas with wide-spread refusal or drop-out, folk media can be deployed to address the concerns and issues. Health camps with a doctor’s consultation have also helped in reducing drop-outs in some areas.

Module 5: Addressing demand side issues in Immunization | 33VIII: Tools for better communication

Use of Immunization/ MCP /child health cards for communication

The card is a vital record for parents and a communication tool for the health provider. The MCP card is well designed and if well explained the care giver can understand many things from the card itself.

The schedule for each vaccine as well as many pictures in the card to inform the care-givers about essential care required during pregnancy and childhood.

The due-dates for the next dose should be entered in by the health provider and explained to the care-giver.

Poster with 4 messages:

Every health worker should have a simple job aid with message guidelines. A vaccinator usually has only a few seconds with a child and time for just a brief exchange.

The poster with four messages should be liberally used to remind health workers on what to counsel and remind parents till it becomes an ingrained habit.

Dates of vaccination day at session site:

When vaccination sites have details of services as well as session days written on the wall or on a board, it helps people to be aware of the services.

The display of village session days may be done at a central community hall or school of the villageSome villages have also gone so far as to write the names of the beneficiaries for the next session on a board or wall-painting, serving to remind the beneficiaries who need to turn up on the next session

day.

Flip charts, pamphlets and fliers:

To help mobilizers and health workers communicate effectively and correctly about immunization issues, several flip charts, pamphlets and fliers have been designed. They can be read out to guardians/ beneficiaries or given to them for them to read. However while reading these out care should be exercised to ensure a two way communication. In order to get copies of these pamphlets you may contact your State EPI officer of IEC consultant. In some cases the state / country Unicef office/ website may also be able to supply some prototypes of the material.

The due list for the next session day on display at the village community hall

A group of community mobilizers being given training on the use of flip charts for IPC in Immunization


Short movie on Immunization related issues

Movies and short skits have been developed to increase awareness for many public health issues including immunization. They are used in community gatherings like village markets, fairs and festivals. They are also used in smaller meetings organized for health promotion by local health service providers. These days with the plethora of CD and VCD players in rural homes, copies can easily be distributed even for home viewing.

Where ever the screening, a small group discussion or a question-answer session following the viewing will help reinforce the messages seen.

A series called “Ek disha” developed by Unicef country office consist a series of short skits where village women discuss issues related to immunization. The central character “Ammaji” is the wise old lady of the village who advises the younger mothers on correct health practices.

Community monitoring tool: My village my home

This resource is a community self-monitoring tool designed for community workers. Its made to use for the purposes of an annual village head count of infants, particularly newborns, as an aid in tracking their vaccination status. It is a drawing of a house in which each infant’s name is placed on a line that represents a plank of a house, starting at the bottom with older infants and “raising” the wall of the house using a line for the name of each infant until the newest infant’s name is at the top. Planks are added as blank lines for the newborns of the future 12-month period. Once a roof is drawn, the house is hung on the wall of the health post where immunization takes place. The names are checked against the post’s birth register. Each infant with a completed third dose of the diphtheria-pertussis-tetanus vaccination (DPT3) is marked by coloring in his/her plank.

Instructions include congratulating parents when their child’s vaccinations appear complete on the village poster, and reminding parents whose children are not yet finished with the vaccination series to visit the health post. A new record is made each year, and the old ones are kept as examples to show the village’s degree of success.

Can download details from: http://www.comminit.com/en/node/299847/292

FAQ on Routine ImmunizationFlip chart on Routine Immunization Hand out on Routine Immunization


Mobile reminders

As the reach and utility of mobile phones in India is steadily increasing by the day, several concepts are being explored to see whether and how mobile phones can be used effectively in communication for immunization.

A variety of uses ranging from immunization data uploading for health workers for the mother child tracking systems to reminders to mobilizers and guardians for their next vaccine due date is being explored.

While such activities are still in their pilot phases one can be optimistic in utilizing new means of communication and technology in improving immunization and other public health programs on the whole.

Below is an illustration of a concept being explored by the BMG Foundation to improve immunization tracking to reduce drop-outs.


The following steps would help the manager and his communication team members prepare a comprehensive communication plan for his area.

Problem Identification Comminication Method(s) Detailed Plan

Micro plan revised and new session sites operational

Folk media Poster and banner Wall printing

Drum beaters in villagers announcing about new outreach sites locations and their timings.Poster and banner for each new session site.Wall writing in community hall as well as new session site announcing session days, services and timings.

New vaccine introduced in the National schedule

Hoarding

FAQs

IPC sessions

Movie skit and flip charts

Hoarding in the hospital campus showing new vaccine, its benefits and schedule.

FAQs to health workers and mobilizers including IPC sessions of manager with health workers and health workers thereafter with mobilizers and guardians.

Movie skit and flip chart to help explain details about new vaccines.

Rumour in village X about side effects of measels vaccine

IPC

Folk artist performance

IPC with influences and guardians to explore root and reasons of rumour.

Fold artists performance to dispence rumours: puppet show

Newly elected village representatives enthusiastic work for peoples health

Advocacy

Fliers and handouts

Advocacy with these members during their meetings.

Fliers and handouts explaining basic information as well as how they can contribute

one sector in the block has high drop out rate

IPC

Social mobilization

Job aids on 4 key messages

IPC of supervisory staff with health workers and mobilizers to understand their performance and reasons for drop out followed by counselling.

Training of health workers and mobilizers on effective counselling, tracking and IPC drop-out beneficiary families.

Village with newly formed self help group wanting to participate in Immunization

Due list wall writing

My village my home poster

Self help group trained to assist mobilizer on calling due beneficiaries, training on preparation and use of due-lists training on making “My Village My Home” poster and each member entrusted with following up with a group of beneficiaries.

IX: Making a comprehensive communication plan

1. Identify your communication problem

2. Decide on the best communication method/method

mix to address the problem

3. Plan meticulously on all aspects and implement

accordingly

Module 5: Addressing demand side issues in Immunization | 39Final Assessment

1. A set of targeted actions, which aim to ensure support for programme implementation at all levels.

a) Advocacy

b) Behaviour Change Communication (BCC)

c) Information Education and Communication (IEC)

d) Lobbying

2. The demand for immunization can be increased by which of the following way?

a) Providing consistent quality and reliable services

b) Creating awareness and visibility of immunization services through hoardings, banners, posters, etc

c) Communicating and Involving the community

d) All of the above

3. What does C stand for in ABCs?

a) Community satisfaction

b) Communication through middle and mass media

c) Care and consultation within the community

d) None of the above

4. Folk Media represents a communication through

a) Mass Media

b) Electronic Media

c) Traditional Media

d) Interpersonal Communication

5. In a village, there is wide-spread refusal of immunization within a community. What could be the most suitable communication system to address the concerns and issues to that community?

a) Electronic Media

b) Folk Media

c) Mass Media

d) Interpersonal Communication

6. Behaviour Change Communication is

a) A strategy, which refers to the systematic attempt to modify/influence behavior, or practices and environmental factors related to that behavior, which indirectly or directly promote health, prevent illness or protect individuals from harm.

b) Any effort to influence policy and decision makers, to fight for social change, to transform public perceptions and attitudes, to modify behaviors, or to mobilize human and other material resources.


c) Combined strategies, approaches and methods that enable individuals, families, groups, organizations and communities to play active roles in achieving, protecting and sustaining their own health.

d) Any form of endogenous communication system which by virtue of its origin from, and integration into a specific culture, serves as a channel for messages in a way and manner that requires the utilization of the values, symbols, institutions, and ethos of the host culture through its unique qualities and attributes.

7. The following diagram represents communication through

a) Mass Media

b) Electronic Media

c) Interpersonal Communication

d) Folk Media

8. The following are the simple procedure to follow during Inter Personal Communication

a) Greet, Ask, Help, Tell, Return, Explain

b) Ask, Tell, Help, Explain, Greet, Return

c) Tell, Help, Return, Ask, Explain, Greet

d) Greet, Ask, Tell, Help, Explain, Return

9. One of the most common cited reasons for barrier to immunization is

a) Lack of information

b) Poor synchronization of supply and demand

c) Demeaning or punishing experience for the parent

d) Concern about side effects

10. What are the steps of effective advocacy?

a) Gathering local facts and figures related to immunization

b) Identify target audience

c) Building a plan and engaging allies for activity

d) Measuring the effectivity of the results of your advocacy

e) All of the above

11. Proverbs, concerts, gong beating and storytelling are the types of

a) Mass Media

b) Folk Media

c) Interpersonal communication

d) Social Mobilization


12. Read the following case study of conversations exchanged between the Health Worker and the Mother of the child in a vaccination center:

HW: Baby Y, Please come.

Mother: Yes and stands up.

HW: How are you and your baby today? Can I see the card?

Mother: Sorry Sister today is my first day so I do not have a card.

HW: Don’t worry; I will give you a card. (The HW records all the necessary details and asks the mother to get the baby ready for vaccination.) I confirm that your baby’s name is Y and he is two weeks old?

Mother: Yes sister, thank you.

HW: I am going to give your child a vaccine on his left upper arm and some drops into his mouth. The vaccine in the upper arm will protect your child against tuberculosis, which gives a chronic cough. The drops will protect against polio which can make the children cripple/lame. The injection does not give much pain but may give a small lump which will subside after a few weeks. All you have to do is to keep the injection site dry and the drops do not cause any problems.

Mother: Thank you sister.

HW: (HW records the details in the card and explains to the mother the next date and time for immunization and gives mother the card.) Do you have anything to ask?

Mother: Yes, what if I miss the next immunization date?

HW: I know it is not easy to keep all the immunization appointments but you should try. Immunizations are important for protecting your child. If you miss the appointment, come on the next immunization day, every Wednesday …….that is even if your child is sick.

Mother: Thank you sister…I will make sure that my child does not miss any immunization appointment.

HW: Thank You, Mrs. B and see you in a four weeks time…bye

The above example is a type of

a) Focus Group Discussion

b) Inter Personal Communication

c) Information, Education and Communication

d) Behaviour Change Communication

13. For role of ASHA in mobilizing community support, which of the following are essential

a) Timely and correct payment of incentives

b) Ensuring ASHAs have complete knowledge of vaccines and the immunization schedule

c) Helping ASHAs to build good relationships with village influencers

d) Knowing about the health services, commitment, good communication skills and use of user friendly and effective tools


14. Which of the following is not an action carried out by mobilizers to prevent and address issues of drop out?

a) Filling out the health card and explaining it

b) Maintaining a complete list of beneficiaries

c) Tracking registers and identifying ant drop-outs from the same

d) Visiting beneficiaries after the vaccination day

15. Decide on the best communication method / method mix to address the problem for the following identified problems.

A. New vaccine introduced in the National schedule

A. Folk Media, Banners, Posters and wall writings

B. One sector in the block has a high dropout rate

B. IPC, Folk Artiste Performance

C. Micro plan revised and new session sites operational

C. IPC, Social Mobilization, Job Aids on 4 key messages

D. Rumour in the village X about the side effects of Measles vaccine

D. Hoardings, FAQs, IPC, Movie skit and Flip Charts

Options:

a) A-C; B-A; C-D; D-B

b) A-B; B-C; C-D; D-A

c) A-D; B-C; C-A; D-B

d) A-C; B-D; C-B; D-A

Module 5: Addressing demand side issues in Immunization | 43References:

• Behaviour change perspectives and communication: Guidelines on six Child Survival interventions; Renata Seidel: AED and John Hopkins Bloomberg school of Public Health

• Communication For Polio Eradication and Routine Immunization Checklists and Easy Reference Guides World Health Organization UNICEF USAID (BASICS and CHANGE Projects) September 2001

• Interpersonal Communication Skills for IPDs Workshop Guide for Vaccination Teams, Supervisors & Community Social Mobilizers Sara Krosch UNICEF/STOP Communication Consultant July 2010

• Learning to Listen to Mothers Project Concern International, Riau, Indonesia

• Reach of media and interpersonal communication in rural Uttar Pradesh: Implications for behavior change communication Population Council. 2010

• Strengthening Immunization Programs The Communication Component Lora Shimp Basics II, USAID

• Training for Mid Level Managers (MLM) 2. Partnering with communities; IVB, WHO

• Why Invest in Communication for Immunization? Evidence and Lessons Learned. Silvio Waisbord Heidi J. Larson, USAID

Module 5: Addressing demand side issues in Immunization | 45Facilitators’ guide:

Module 5: Communication and demand generation in immunization

(3½ hrs classroom )

Section Method (time) Tool1. Introduction Show graph (CES 2009) and discuss (10 mins. )

Group discussion: divide participants into three groups as given in the figure. Try to find out issues as to why they remain in their particular groups. Discuss what can be done to ensure all beneficiaries in the community become fully vaccinated by the time they reach 1 year of age.(20 mins)

Picture: 3 concentric circles and group discussion

2. Provide quality consistent services

Modular reading in small groups. Try and relate to the situation described in the chapter and to answer the questions given in the text. Get the groups to agree on key steps in improving the access for the last house in the distant village. (10 minutes)

Module

3. Arrange for visibility and awareness of services

Group Discussion on how managers can make effective use of communication materials. Divide the participants in 4 groups and let them present a solution to how communication materials can be used effectively in the following situations 1) Posters and wall paintings 2) audio jingles on radio or videos 3) banners 4) stickers, fliers and handouts. Discuss where, how and when you should use the above medias for communicating your message most effectively. (10 minutes)

Available communication material as developed and used in the state can be brought to demonstrate to the participants.

4. Communicate with and involve the community

General discussion: Ask participants to give examples of how the village health and sanitation committee can help in planning, implementation and monitoring. Discuss. (10 minutes)

Module section C

5. ABCS of communication

5 a. Advocacy with leaders, influencers, organizations and groups

Modular reading on advocacy followed by group discussion: Ask the participants to give examples of effective advocacy and how to

Module


Discuss about Roshni and Meena’s behaviours and the outcome in their work. (15 minutes)

Divide into groups and make role plays of good and bad behavior related to immunization 1) among health workers, 2) among caregivers, 3) community and public leaders. (30 minutes)

Outline/script of role play

5 c. Communication through mass, folk media

Discuss how mass media, folk media / traditional media can play a positive role, and how to involve local media. (15 minutes)

Selected facility (cold chain store), session site and field area.

Interpersonal Communication

Group exercise; practice gather technique

(30 minutes)

Give two scenarios and communication objectives which will have to be communicated using a gather technique


Section Method (time) Tool6. Social Mobilization

7. Addressing issues of drop out through communication

Divide the participants in 3 groups. Give them sections 6, 7a and 7b to read as a group. They will then present key points on the following(a) How managers can ensure effective Social

mobilization of beneficiaries for immunization through ASHAs

(b) How can managers ensure Prevention drop-outs through good provider behavior of health workers and ensuring reliable services

(c) How can managers ensure reduction of drop outs by following up on tracking and counseling mechanisms

(30 minutes)

Modular reading followed by presentation

8. Tools for better communication

Demonstration of available tools and discussion on possible tools that can be developed

(15 minutes)

Communication tools as available.

9. Making a comprehensive communication plan

Draft a communication plan. Divide the participants in 3 groups and let them draft communication plans for the issues listed in page 24.

(15 minutes)

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