The Drum Beat 299: Routine Immunisation Communication - Survey Results

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This issue of The Drum Beat provides a summary of the findings from a Routine Immunisation Communication Survey conducted in March 2005, which was developed jointly by The Communication Initiative (The CI) and one of its partner organisations, The CHANGE project. The survey was designed to elicit personal experiences from those who have worked in any or all of three key problem areas which have been identified in the field of routine immunisation. The goal was to document what has been done to address these problems and to identify successful approaches which have been implemented around the world. The ultimate aim is to share these lessons learned with the routine immunisation community in the hope that this shared knowledge will contribute to the development of more effective routine immunisation programmes and improved coverage rates.

Click here to download the full Final Survey Report in PDF format.

For more information, contact Warren Feek at wfeek@comminit.com

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SURVEY OVERVIEW

The three key problem areas addressed in this survey were:

1. Too many caregivers don't know when and where they should bring their child for his/her next vaccination.
2. Too many caregivers are reluctant to return for subsequent vaccinations because of unpleasant experiences in the health facility.
3. There is insufficient focus among health staff and caregivers on the need for children to be fully immunised by their first birthday.

The survey was segregated into 5 Parts.

Part I recorded information about the demographic profile of the respondents including their nationality, current country of residence, the organisation with which they are currently employed, and their professional role within that organisation.

Parts II through IV recorded their actual experiences implementing programmes designed to address the three key problems stated above. The respondents were asked a number of questions including: how they identified the existence of the problem; factors that were perceived to cause the problem; approaches taken to address those causes; and details regarding the relative success of those approaches.

In Part V, respondents were asked for their opinions regarding the most effective solutions to these challenges. This opinion section was answered both by those with and those without direct experience addressing the three key problems.

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DEMOGRAPHICS - SUMMARY OF PART I RESULTS

Demographic data about the respondents was collected in order to understand the working context of the experiences reported. In total, 96 survey responses were received.

ORGANISATION - A wide range of organisations was represented by the various respondents, with substantial numbers working in national non-governmental organisations (NGOs) (19%), academic/training institutions (17%), government departments (16%), and international NGOs (14%). The single organisation with the greatest representation was UNICEF (13 respondents).

COUNTRY - Africa was the most common region of current residence (42%), followed by South/Central Asia (19% - with the majority in India), followed by North America (16%). Nationality was also tracked and aggregated using the same regional groupings and there was a relatively high degree of co-linearity between these responses, with 73% of respondents noting that they currently resided in the country of their nationality.

PROJECT LOCATION - In addition to these overall demographics, the survey gathered information on the location of the projects referenced by the respondents in Part II-IV. These activities were predominantly carried out in Africa or Asia and were most often directed at populations greater than 1 million.

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FROM THE EXECUTIVE SUMMARY

The qualitative results from Parts II-V of the survey are reported in the information below from the Executive Summary. Results within each of these 4 sections were often overlapping in content and consistent messages emerged. A synthesis of the responses to the open-ended questions, as well as direct quotes related to 10 dominant themes, is provided.

These have been distilled into THE TOP 10 LESSONS LEARNED, as follows:

1. LISTEN TO THE COMMUNITY VOICE...RIGHT FROM THE START

ENGAGE: Respondents indicated that a sustainable programme must be supported, monitored and fostered within a community - therefore community leaders, NGOs, mothers' groups etc. must be involved in discussions around planning, educating, and implementing immunisation programmes.

"The lesson here is that you need a good understanding of social and cultural condition, backed by thoughtful research and insightful interpretation of findings. You also need to be able to stand up and say that the current approach is not working, and have the stamina and grit to modify your approach mid course."

- Pakistan, Programme Officer

"Planning, planning and more planning followed by Microplanning are the very best tools that lessons learned work quite well. Listen to the targeted people!"

- Angola, Programme Manager

EMPOWER: Many respondents noted the importance of empowering the community by ensuring that they themselves take responsibility for ensuring participation in the immunisation programme. This included programmes such as "adopt a family", which made certain individuals within the community responsible to get families out to be vaccinated.

"We can significantly improve the immunization coverage in our health districts if we successfully implement communication strategies such as advocacy, social mobilization, interpersonal communication with the use of front line local mobilizer, training of health staff in communication and supervision monitoring of activities. We must empower the communities on health and vaccination instead of asking them to participate during vaccination campaigns."

- Cameroon, Communication Consultant

"Involve the community members more. Have a dedicated staff for monitoring communicate in the very many local languages, even if that's a difficult proposition. Find some workable solution to their livelihood options at least have discussions."

- India, Programme Manager

LISTEN: According to respondents, it is also vitally important to report back to the community what is actually happening - for example, how many children were immunised, who was missed - to engage the community in solving the dilemma. They suggested that it is important to give the caregivers a way to provide feedback - for example, a means of evaluating the services received at the health centre, without fear of retaliation from the health workers. Feedback must go to a separate, independent body.

"As a supervisor, manager put in a non-threatening complaints system for carers. Empower carers to complain if the service is not responsive to their needs."

- Australia, Researcher

2. MORE TRAINING, SUPPORT AND MOTIVATIONAL TOOLS FOR HEALTH WORKERS

Overwhelming input was received on the need for improved training for Health Workers (HWs), including:

• the need for interpersonal communication training;
• an increased awareness of HW impact on caregivers;
• HWs' crucial role in educating the caregivers; and, in some cases,
• improved medical training, both in sterile technique and knowledge regarding when immunisations should be given.

Many respondents also acknowledged that providing quality vaccination services is hard work - and it is critical to look for ways to improve motivation among health workers. Techniques that were used ranged from providing some form of recognition, providing more support (i.e. having community members working with health workers to provide non-technical support), and providing more money.

"Problem: Not enough motivation for health volunteers or promoters/ Design a national public impact strategy named 'Star Vaccination Promoter'."

- Communication Programme Officer, NGO, Peru

"Routine immunisation must be a sustained effort where care must be taken to make services user friendly, i.e. correct body language of the staff, pleasant behaviour, following sterile techniques, maintaining records, availability of vaccine and regularity of sessions, etc."

- Regional Technical Advisor, CORE PEI Programme, India

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3. ENSURE THERE IS GOVERNMENT SUPPORT AND ADEQUATE FINANCING...AND BE REALISTIC

Another recurrent theme was the importance of government support of vaccination programmes, as well as national and international sourcing of funds. Respondents also noted that it is important not to promise more than can be delivered - to recognise up front the existing limitations, particularly financial - to avoid unrealistic expectations.

"Vaccinations are not available due to lack of funds within the government to purchase these vaccinations."

- Malawi, Researcher

"Resolved to establish community health facility and other related infrastructure within the sublocation and carry out Awareness. We recommended to seek government and international donors to help the community set up the facilities through fund raising methodologies."

- Kenya, Executive Director

"We should abandon the idea of think that we could do everything. We need to understand that our main role is invest in the formation and training of those pilot who will be more effective than us in getting the job done. In other words: 'empowerment.'"

- Egypt, Communication Trainer

4. BE CREATIVE - UTILISE MULTI-CHANNEL COMMUNICATION APPROACHES

Many respondents cited successful multi-channel approaches that combined high technology and mass media activities with more localised community outreach and interpersonal techniques.

"We would attempt to improve actual work or NGOs on the ground in respect of awareness building strategies. Found out that the quality of information shared was at times poorly delivered. We would also increase the amount of Alternative Media usage ie. we would use more theatre and folk singing approaches which are very popular and acceptable as forms of information dissemination to rural and other communities."

- São Tomé & Príncipe, Programme Officer

"We integrated the messages into our TV and Radio dramas and developed a MCH handbook distributed to 1 million people. We also developed an education pack with a unit on immunisation."

- South Africa, Programme Manager

"Short text messages via mobile phones and also reaching the people on foot."

- Ghana, Journalist

5. COORDINATE THE PROGRAMME DELIVERY - AT THE NATIONAL, STATE AND LOCAL LEVELS

Many respondents stressed the importance of effective support at the national, state, and district level, so that programme implementation is consistent and effective.

"More coordination between sectors and development actions are needed in a place like Nigeria. Individual sectoral actions taken over the years has meant that strategies succeed only to the extent of the specific ministerial involvement. Greater inter-sectoral actions required. State level political advocacy at all levels required."

- Nigeria, Programme Manager

"National IEC program, linked to other system elements: - rehabilitation of immunisation service delivery systems - community action and participation program - village volunteer support."

- Papua New Guinea, Technical Officer

6. MAKE HEALTH CENTRES MORE ACCESSIBLE TO CAREGIVERS

Many respondents identified problems with access to health centres. They suggested some concrete steps towards improving access. These included setting up outreach health clinics on a regular basis - making sure the community is engaged, involving them in planning timing of vaccination days and charging them with the responsibility to maximise attendance. They also cautioned to be aware of the difficulties faced by many caregivers (for example: long distances travelled, precious time taken from their work, frustration at waiting and then not being immunised because there are not enough children attending to open a particular vial of vaccine.)

"Due to vaccine stock out, venues of immunization changes, if there are no efforts to redirect clients to the right place, most will not be able to access the services."

- Nigeria, Researcher

"To target days/sessions which do not have other activities e.g. market days or planting sessions in most cases if you go to that community the turn up will be low, on such days immunisation is not the priority."

- Uganda, Public Health Trainer

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7. UTILISE STANDARDISED REPORTING AND PROCEDURES WHEN PROVIDING HEALTH SERVICES

Many tools have been developed to assist health workers in providing full and complete care to caregivers during their visits, including vaccination cards and standardised checklists to be reviewed with caregivers on each visit. Several respondents noted the importance of these types of tools for health workers to ensure that consistent, quality service is provided to caregivers. The need for health workers to ensure that caregivers do not leave without a follow-up appointment was also stressed.

"The tool developed is the 'carte MERCI' which lists the primary messages that should be communicated during a vaccination session. It is part of the national EPI tools and is to be posted in every health facility."

- Congo (DRC), Technical Officer

"The project gave community health workers supplemental training emphasizing the immunization schedule and gave caregivers child health cards."

- South Africa, Researcher

8. INTEGRATE, COMBINE AND EXPAND THE SCOPE OF SERVICES PROVIDED...WHENEVER POSSIBLE

According to respondents, a holistic approach is generally very well received. If it is possible to provide additional crucial services (i.e.: malaria medication), caregivers have additional motivation and increased benefit from attending the clinic.

"Provided and Conducted additional health services such as Health Camps, sanitation clearing activities and installation of household toilets."

- Project Director, PEI CORE Group, Angola

9. INVOLVE THE SCHOOLS

Respondents gave several examples of effective involvement with the schools - children educating their parents, their siblings and even adopting families and working with them.

"One of the strategies is to work through schools to reach parents "adopt a family". School children adopt a family in their community. Through this relationship they educate their family on immunisation, hygiene and sanitation practices. These children attended schools that have been constructed through community efforts (supplemented by donor, govt. and NGOs) and thus there are already strong links between the schools and the community. For example, the community utilises some of the school facilities (e.g. furniture for weddings and other function), school water wells are also used by the community members, etc."

- Sierra Leone, Programme Coordinator

"Emphasized the importance of RI at mothers' meetings. Held polio classes at schools where children were told to bring their younger siblings for outreach sessions, esp. the newborns for birth OPV and BCG."

- Regional Technical Advisor, India

10. BUILD INDEPENDENT EVALUATION AND IMPACT ASSESSMENT INTO PROGRAMMES

Several respondents noted the importance of improving the current scope of monitoring and evaluation tools and generating measurable outcomes.

"M&E (Monitoring and Evaluation) is still a challenge for communication in Africa as the most effective IPC (Inter-Personal Communication) activists very often are illiterate."

- Liberia, Technical Assistance

"There is amazing variation from location to location and among different ethnical groups that it is difficult to ascribe causality for low coverage. One needs to examine morbidity and mortality and compare these against those immunized and those unimmunized. The true answer is relevant when community norms brings awareness about which children are immunized and which are not AND WHY NOT! The community leadership must focus on encouraging both the parents (or child caretaker) and the MOH to provide immunization services on a schedule that assures infants CAN be immunized by 12 months of age. 2) Measurable positive outcomes must be recognized by parents when children are immunized, e.g. lower morbidity and less mortality."

- Project Director, PEI CORE Group, Angola

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CONCLUSION

Based on the responses from the people doing this work, the authors suggest that these "Top 10 Lessons Learned" are features essential to any programme designed to improve the scale and scope of effective routine immunisation.

Click here to download the full Final Survey Report in PDF format.

For more information, contact Warren Feek at wfeek@comminit.com

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Rather than getting back into the trenches of the 1990ies, the challenge today - in times of a strong treatment agenda - is to reassess our communication science, models and practice when putting HIV/AIDS prevention on the agenda.

[For context, please see The Drum Beat 297]

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This Issue was written by Shan Thomas and Greg Long.

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