Refresher Training for Frontline

Health Workers in Expanded Program of Immunization(EPI)

Module 4

Communicating With Caretakers and Communities for Improved Routine

Immunization Coverage

January 2005 Addis Ababa, Ethiopia

A collaborative in-service training jointly developed by the SNNPR, Oromia and Amhara Regional Health Bureaus and the ESHE Project

Amhara Region Oromia Region SNNP Region

Essential Services for Health in Ethiopia is implemented by John Snow, Inc. in collaboration with Abt Associates Inc., the Academy for Educational Development, and Initiatives, Inc.

Financial support for this module was provided by the US Agency for International Development, contract number 663-C-00-04-00403-00. The views expressed in this document do not necessarily reflect those of USAID.

The Refresher Training Modules Were Principally Adapted From the Following Sources:

• WHO Immunization in Practice

• WHO Mid-Level Managers Training

• WHO module on Increasing Immunization Coverage at Health Facility Level

• MOH and WHO/Ethiopia, “Improving routine immunization coverage in Ethiopia through Reaching Every District (RED) approach.”

Draft set of five modules developed by FMOH/Nigeria and BASICS II

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Table of contents

Acronyms ................................................................................................... ii

About Module 4………..……………………………………………..…... iii

The role of Behavior Change Communication and community

mobilization in immunization programs………..........…............................ 1

1. Behavior Change Communication for improved routine

immunization coverage ……………….......................................... 2

2. Effective communication skills …………………………………... 8

3. Five key messages about immunization ......................................... 14

4. Involving communities in promotion and planning of

immunization services …................................................................ 17

Annex 1: Mothers’ Concerns about Immunization………………………. 22

Annex 2: EPI Invitation Leaflet & Immunization Diploma ……………... 29

Annex 3: Community monitoring form for immunization and

tracking dropouts…………........................................................ 31

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Acronyms BCG Bacillus of Calmette and Guerin (tuberculosis vaccine)

CBRHA Community Based Representative Health Agents

DPT Diphtheria-pertussis-tetanus vaccine

DT Diphtheria tetanus vaccines

EPI Expanded Program on Immunization

HB Hepatitis B

HEP Health Extension Package

OPV Oral polio vaccine

TT Tetanus toxoid

TBA Traditional Birth Attendants

VAD Vitamin A deficiency

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About Module 4

This module deals with Behavior Change Communication and its role in improving routine immunization coverage. It identifies essential messages for caretakers and explains how to effectively communicate these messages—both as a means to provide valuable information that can be used to address mother’s concerns about immunization. It explains how to realistically involve communities in immunization promotion and planning in order to increase demand for and use of immunization services. This module is intended for the use of the health worker at the immunization service delivery point.

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The role of Behavior Change Communication and Community

Mobilization in Immunization Programs

Unfortunately, Wubalem and Tigist’s stories are familiar ones. A considerable number of mothers do not know the importance of immunizations. Even if mothers do know, far too many mothers who bring their infants for their first immunizations DO NOT go on to complete the full immunization series. Why?

• Mothers may not know that they need bring their baby for further immunizations • Mothers may not know the day scheduled for the next immunizations • Health workers may not arrive on the day set for immunizations

Mothers may not know the immunization team has arrived, etc.

The Story of Wubalem and Tigist Wubalem had just returned home from fetching water. She was tired as the pump is far from her home. Her eldest daughter, Fatuma, was watching the baby, Tefera. Fatuma told her mother that she had heard an announcement that morning about immunizations being held today in the kebele. Wubalem had already brought Tefera to immunizations once before and the health worker told her the last time that she should bring her baby back for more immunizations. Wubalem quickly put Tefera on her back and went to the immunization place with the immunization card. On her way, she ran into her neighbor Tigist. She had a baby about the same age as Tefera, though her baby had never received any vaccinations. Tigist told Wubalem that she went to have her baby immunized because she heard that it would protect her baby, but when she arrived some other women told her that the health workers had already left. Tigist said that it probably wasn’t that important anyway. But Wubalem remembered that the health worker said that immunizing her baby was important. Not knowing who to believe, Wubalem walked back home wondering what to do next... ...back at the health center, the nurse who went for outreach that day reported to the center head about the days outreach activities. The health worker said that he was disappointed by the low turnout of women: ” mothers in that kebele just don’t understand the importance of immunizing their children”...

Q1. What do you think about what the health worker has said? Q2. What do you think Wubalem and Tigist will do? Q3. What could the health worker have done so that more mothers would have arrived for immunizations? Q4. Suppose you are the health center head, what questions would you ask the nurse about what happened? What advice would you give?

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1. Behavior Change Communication

Behavior Change Communication plays an important role in immunization programs. By improving health worker communication with caretakers and communities and focusing on messages that address mothers’ concerns about immunization it and help reduce the number of “left-outs” (unreached) and drop-outs by raising community support and demand for services. 1.1 Desired immunization-related behaviors As described in other modules, immunization services are less likely to be used by people who are:

• Uninformed • Dissatisfied • Too busy • Poor and powerless • Misinformed • Distant

Other modules discuss health system actions that can address these problems, such as shifting session schedules and ensuring that vaccines are available when clients seek them. This module describes how to take a comprehensive approach to behavior change in order to improve the delivery of immunization services and encourage their appropriate use. Achievement of immunization goals is affected by the behavior of many groups, including: community and religious leaders, health care providers, managers and supervisors, caretakers and their families. The focus of this chapter is on health care providers, caretakers, community leaders, and community-based health workers (community health promoters, CBRHA’s, TBAs, etc.). Some of the desired behaviors for different groups that affect immunization services are listed on the following page.

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Figure 1

Desired Immunization-Related Behaviors 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. • Seek tetanus toxoid immunizations for yourself and bring your health card. (This is

applicable to 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. Health Workers • Perform immunization tasks correctly, including those that ensure safe injections. • Give mothers and other caretakers essential information and treat them respectfully. • Work with communities to schedule and organize services to make them convenient

for parents. • Praise families whose children are fully immunized by one year of age. 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 his or her first year

of life. • Inform families about outreach services, supplemental immunization activities, and

new vaccines and 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. Political and Public Health Leaders • Allocate sufficient financial and human resources for immunization services. • Show personal support for immunization services.

Source: WHO, UNICEF, and USAID, 2002

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1.2 What is Behavior Change Communication (BCC)? Behavior Change Communication (BCC)

• Is an interactive process that includes health workers, communities and caretakers • Is integrated into an overall immunization program • Is a process of developing tailored messages and approaches using a variety of

communication channels • Promotes positive behaviors by families, health workers, and communities and

encourages sustainable behavior change The Role of BCC

• Achieve higher coverage rates for all antigens and reductions in missed opportunities, unreached children, and drop-out rates by mobilizing communities to support and plan immunization services;

• Improve quality of services to meet demand, improve interaction between health workers and communities, and improve safety of injections and safe handling of vaccines; and

• Prevent or dispel misinformation and doubts related to immunization through the use of multiple channels, information sources, and media that influence the population and public opinion.

Some Specific Goals

• Advocating to make immunization a priority of local decision-makers • Educating caregivers about the importance of immunization to have their children

completely vaccinated • Enabling health workers to engage communities to raise awareness about immunizations,

relay specific information about the time and place of immunizations, and identify newborns and track defaulters

• Improving the communication skills of health workers to better listen and respond to caretakers concerns

Communication Channels

• Interpersonal face-to-face (health worker, community health promoters) home visit (HEP agents, community health promoters) group discussion counseling in consultation

• Traditional drama (community health workers) songs puppet shows community theater

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• Print Material leaflets (EPI Invitation Card—Annex 2) posters

immunization diploma (Annex 2) flip charts • Mass media radio television newspapers and magazines movies

Experience shows that mothers who know about immunizations realize the importance of bringing their infants for immunization. How health workers approach and work with parents, key individuals and community groups will have an impact on the demand for and use of immunization services. Therefore, it is important to understand how both caretakers and health workers require encouragement and support to increase the number of fully immunized children. 1.3 How does change happen? Table 1 below describes the stages of behavior of caretakers and health workers related to information. It indicates what type of communication is needed in order to promote desired immunization-related behaviors Remember:

While it is important to focus on caretaker behaviors related to immunization, it is equally important to highlight how health worker behaviors impact immunization coverage.

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Table 1. Stages of Behavior Change

Stage of Behavior

Characteristics Example What is needed to remedy the situation

Pre-Awareness People in this stage have no intention to change behavior in the foreseeable future. They are unaware of the risk, or deny the consequences of risky behavior. They just don’t know.

Caretaker: “I’ve heard about immunizations for my baby, but babies usually get sick.” Health worker: “People in this area already know about immunizations. If they don’t immunize their children it is because they don’t want to.”

Information

Awareness People are aware that a problem exists, are seriously thinking about overcoming it, but have not yet made a commitment to take action

Caretaker: “I know that immunizations are important for my baby, but I’m not sure if this is really true.”

Information, persuasion, family and community support

Contemplation/ Intention

People intend to take an action in the near future and may have taken some inconsistent action in the recent past

Caretaker: “I’m now convinced that bring my baby for immunization is the best way to protect her; but how will I convince my husband?” Health worker: ”Many mothers have told me that they would bring their infants to immunization if they knew a day in advance so they can arrange to take the time, but how can I let them know?”

Persuasion, encouragement, support

Trial/Practice People modify their behavior, experiences or environment to overcome their problems; the behavior change is relatively new

Caretaker: “The health worker thanked me for bringing my baby for immunizations and told me what immunizations my baby was getting. It was different than what I had heard before about immunizations!”

Praise, encourage, negotiate, review benefits

Adoption Individuals work to maintain the behavior change over a long period of time

Health worker: “Having the community health promoters alert women in the kebele two days in advance of immunizations has really worked to get more mothers to attend outreach!”

Praise, congratulate, recognize, reinforce knowledge about benefits

Maintenance/ telling others

Wouldn’t think of doing it any other way… People talk about their experience and advocate for others to try it, too.

Caretaker: “All of my children were fully immunized before their first birthdays. I put their immunization diplomas on the wall where I can show my family and friends. I now encourage pregnant women and new mothers to bring their child for immunization!”

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Case Studies Case Study: The immunization calendar The nurse at the local health center looks at the immunization calendar posted on the wall of the office. He sees that tomorrow outreach is scheduled for Wanja kebele. The next day, he arrives at the center early and prepares the vaccines for transport. He then takes a motorbike to Wanja. When he arrives he sends a small boy to ask the kebele chairman for chairs and a table. The boy soon returns with the kebele chairman who expresses his surprise at the arrival of the nurse. He explains that no one knew that today was the day for outreach. The nurse looks at the kebele chairman in disbelief and says: “But the date for outreach was clearly posted on the wall of the health center!” Q1. What behavioral stage best describes the nurse’s situation? Why? Q2. What is needed to ensure the community is better prepared for outreach? Case Study: Tigist brings her baby for the first time Tigist has brought her 4–month-old child to the immunization session. She hasn’t brought her immunizations before, because she heard rumors that children become sick after getting vaccinated and she wanted to protect her child. A friend, who is also the kebele CBRHA, told Tigist that a little illness after the immunization is nothing compared to getting the disease itself. So she decided to bring her baby for immunizations, though she still isn’t quite sure about immunizations.

Q1. What behavioral stage best describes this woman’s situation? Why? Q2. What is needed to ensure this child completes the full immunization series?

Case Study: Earn the diploma! Four months ago a health worker talked with a mother about bringing her child to immunizations. The mother brought her baby to outreach where DPT1 & Polio 1 were given. The baby had a slight fever after the immunization. The mother did not worry, however, since the health worker had told the mother to possibly expect mild fever after the immunization and it was nothing to worry about. And to bring her baby back in four weeks for the next dose of DPT & Polio. Now the baby has received all DPT immunizations and the mother says she will bring her baby at nine months old for the measles immunization. She says that she wants to protect her baby and get the immunization diploma! Q1. What behavioral stage best describes this woman’s situation? Why? Q2. What is needed to ensure this mother brings her child to complete the immunizations?

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2. Effective Communication Skills

Effective communication begins when a health worker starts thinking about what keeps people from coming to a health facility and/or what prevents them from returning. Among other reasons (e.g. lack of supply, distance,), caretakers may not get the information they need or may have unpleasant experiences with health workers.

• Traditionally health education relied upon one-way communication from the “teacher” to a “learner”. The assumption was that if we simply tell people what to do, they will do it.

• However, we now know that simply giving information is not enough. As health

workers we need to listen, understand, encourage, and better communicate with individuals and communities so that improved health behaviors become a part of the way people live.

2.1 Qualities of effective communication People will only grasp health messages when they feel respected, encouraged, and when the health worker makes an effort to check if caretakers understand the key points. Health workers and community-based health workers should be aware that effective communication includes the following: • Be warm/friendly:

A friendly contact between a health worker and a mother will establish a good relationship: - Be warm and welcoming - Show respect for the mother - Praise and encourage mothers for brining their child for immunizations

• Encourage the mother/parent: Find out what the mother already know by using terms that she understands. - Respond to concerns about immunizations - Encourage her to continue immunizing her child - Show concern for her particular situation

• Give messages relevant to the mother’s/child’s situation:

The message should: - Be relevant to the mother’s particular situation. - Correct any misconceptions the mother may have.

• Keep messages simple and clear: When communicating with the mother/parent:

- Be straight forward

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- Use simple language understood by the mother. - Summarize the key information.

• Have caretakers repeat what you have said to know if they understand: - Have the mother repeat what they have heard to check for understanding - If you ask “do you understand?” and someone answers “yes” you cannot be sure

that he or she really does understand. - If you ask “when will you bring your child for his next immunization?” and

someone answers with the correct day or date, you know that he or she has understood you.

Remember to always:

• Act respectfully toward the mother/parent. • Praise them for brining their child to immunizations. • Encourage them to continue brining their child until fully vaccinated. • Keep messages simple and clear. • Have the caretaker repeat what you have said.

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Case Study: The following two plays show an exchange between a health worker and a client highlighting some of the common problems in communication. After you read both plays, ask yourself about the quality of the “communication” involved in each. Then you will want to review the “Communication Checklist” the effective communication behaviors to be practiced by health workers.

The Health Worker (HW) and Wro. Almaz, Scene 1 HW:

Baby Yonas! (Shouts towards the row of seated women) . . . Baby Yonas!!

Almaz:

Yes Nurse? (she stands up and moves towards the procedure table with her baby)

HW:

Don’t you listen? Why do you come here then? Show me your card!

Almaz:

(becomes uncertain of what to do and stands in front of the procedure table)

HW:

Just sit down! Don’t waste my time; I have many children for immunization today.

Almaz:

(sits down and gets her baby ready for injection)

HW:

(writes on the card and then gives the baby an injection without any regard for the baby or the mother; he writes on papers on his desk, ignoring the mother )

Almaz:

Please . . . I do not know the injection you gave my child and if I am to bring her

back for another immunization. HW:

Look, are you stupid? Bring that your card. Everything is in this card. You have to be reading this card properly and make it your Bible or Qur’an. You see I have already marked the injection I gave your baby on the card.

HW: (continues):

The card also contains the immunization schedule as follows (head down he

reads the information from the card as rapidly as possible): At birth…………………..BCG & OPV0, HB1 At 6 weeks………………DPT1 & OPV1, HB2 At 10 weeks……………..DPT2 & OPV2 At 14 weeks……………..DPT3 & OPV3, HB3 At 6 months……………..Vit A 1st dose At 9 months……………..Measles, Yellow fever At 12 months……………Vit A 2nd dose.

Almaz:

Please Nurse…

HW:

Madam! No questions. You are wasting my precious time. I have told you that I am always very busy in this clinic. Who’s next? Baby Alemu!

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The Health Worker (HW) and Wro. Almaz, Scene 2

HW: Baby Yonas, please, come this way. Almaz: Yes Nurse (she stands up and moves towards the procedures table with her baby)

HW: Please sit down. How are you and how is your baby today? May I see your card? Almaz: Fine sister! (Sits down and gets her baby ready for vaccination). I do not have a card.

Today is my first day. HW: Don’t worry. I will give you a card. (Health worker takes the card out and records

all the necessary information and directs Wro. Almaz to get her child ready for vaccination). Wro. Almaz can I confirm that your child’s name is Dele, and he is 4 weeks old.

Almaz: Yes, Nurse. Thank you. HW: I am going to give your child a vaccine on his left upper arm and some drops into his

month. The vaccine in the upper arm protects your child against tuberculosis, which give children a chronic cough. The drops prevent polio, that disease which can make children lame. The small injection does not cause much pain. It may give a small lump that will last only a few weeks. You should keep the injection site dry and do not dress it (HW gives the injection on the left upper arm of the child). The drops do not cause any problems.

Almaz: Thank you Nurse. I am so happy you are not angry with me. HW: Wro. Almaz, why would be angry with you? Almaz: Ah! You know the other mothers told me that because I did not bring my child

immediately after birth, the nurses were going to shout at me. Thank you very much. HW: Records the vaccine given and tells Wro. Almaz the date, place and time of the next

vaccinations. The HW also explains that to be fully immunized the child needs to complete several visits before the child’s first birthday. Your next visit will on this same day, Monday, in four weeks time.

Do you have any questions or anything, which you would like me to explain further?

Almaz: Yes, Nurse. What should I do if I miss my child’s immunization appointment? HW: Wro. Alamaz, I know it is not always easy to keep all the appointments, but you

should try as much as possible to keep the immunization appointments. Immunizations are very important for protecting your children against dangerous childhood diseases. But if you fail to keep an appointment, just come on the next immunization day even if the child is sick. We give immunizations every Monday in this clinic.

Almaz: Thank you Nurse, (smiling). I will make sure I do not miss any immunization appointment.

HW: Bye-bye Wro. Almaz, see you in 4 weeks time.

Discussion Compare the behavior of the health worker in the two scenes described above. Q.1: What do you think about the way the health worker dealt with the mother? Q.2: What should the health worker have done under both circumstances? Q.3: How well did health worker understand the mother’s situation and communicate?

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2.2 Communicating with groups Another opportunity for communicating about immunization presents itself when groups of people are gathered, perhaps waiting for immunization or attending community meetings. Discussions between health workers and small groups of parents can be held as part of immunization sessions and on other occasions in and outside of a health facility to:

• Reinforce positive attitudes and behaviors • Respond to questions • Identify and fill information gaps and correct misinformation • Address people’s doubts about immunizations

The key to communicating effectively with groups is to address the shared interest of the group members. As with individuals, you should deal with group members’ concerns at the outset. Annex 1 discusses some “mothers’ concerns” that have been noted in the past and how these concerns have been addressed. Group Discussion Techniques Discussion provides an effective way to obtain and give information or ideas. Some ways in which you can encourage discussion are indicated below. • Ask what the group knows about immunizations.

- Remember that you are not giving them a test - Let them discuss freely - Ask the mothers what concerns and questions they have about immunizations (See

Annex 1 for commonly asked questions) - Allow participation from as many people as possible

• Ask why some people don’t chose to get children immunized or begin immunizations but don’t

complete them. • Praise individuals for their responses.

• Discuss the five (5) essential messages that caretakers need to know (Section 3.1) • Allow the group to come up with their own solutions to the problems. Let them be part of the

problem solving discussions • Use visual aids such as pictures to illustrate what you are talking about.

- Ask people what they see happening in the picture - What do they like about what they see happening? - How does this relate to immunizations?

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Involve groups in a variety of ways to improve understanding and make learning fun and interesting

• Tell stories and ask people what they think happened in them, and why.

• Sing songs or encourage people to make up their own songs.

• Put on short plays about immunization and encourage group members to create their own.

Remember when discussing with groups to:

• First ask the group to share what they know about immunizations.

• Praise individuals for their responses.

• Encourage them to share their ideas by asking questions.

• Involve as many members of the group as possible in the discussion.

• Allow group members to give their own solutions to problems.

• Use stories, skits, songs, and visual aids for to draw the group’s attention and

make learning fun and interesting.

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3. Key messages about immunization

One-on-one counseling is the best way to give parents information on when and where to bring their child for the next vaccination. However, simply giving people information is not enough; the message must be understood and remembered, as shown in the box.

Always ask mothers/parents to repeat the information you have given them to increase chances that mothers will remember when to return.

3.1 Five (5) key messages about immunization:

There are five (5) essential messages that clients/parents should receive if they or their children are to be fully protected against the EPI diseases: 1) Explain what vaccine(s) is to be given and the disease is that this vaccine will prevent. Tell the mother/parent: • Praise the mother for bringing her baby and herself for immunizations. • What vaccine(s) is to be given given. • What illness the vaccine protects against. At subsequent visits: • Make people feel a sense of accomplishment by praising them for the vaccines they have already

received. • Emphasize the need to complete the schedule to ensure full protection for their children and

themselves. • Tell the mother/parent that the baby will receive an immunization diploma when the baby

completes the fully series of immunizations before his/her first birthday. 2) Explain what side effects may occur and how to treat them Explain to the mother/parent: • the expected side effects for each vaccine given and that they are normal. • that side effects are usually mild compared to the disease the child can get if he/she is not

immunized. • what to do about the side effects. 3) Tell the caretaker the place and time of the next immunization It is important for the mother/parent to understand the place and time for the next immunization session. This is particularly important if you are changing locations as in outreach sessions. Inform the client/parent: • Where to attend the next immunization session • The particular day and time of the next immunization. Explain this in a way that the

mother/parent will understand (on the next market day, “on Monday, four weeks from now”). Be sure that the mother/parent repeats the time and date back to you so that you know she has understood.

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4) Bring the child for immunization even if he/she is sick Immunization is important even for a sick child. Inform the parent that: • If the child has a cold or is not feeling well that he/she should be brought to the health worker. • It is especially important to immunize the sick or malnourished child because they are most

vulnerable to catching serious childhood diseases. 5) Take good care of the immunization card and to bring it every time the mother and/or child come to a health facility. The vaccination card should be kept like a birth certificate. Remind the clients/parents: • of the importance of the immunization card/home health booklet. • that the immunization card is a record of services provided and services still needed to fully

protect the client. Note: Each of the five (5) messages should be given more than once. The likelihood of their being remembered increases if different health workers give them, e.g. the one giving immunizations and the one completing the paperwork at the exit point. Check clients’ understanding by asking questions that require answers other than a “yes” or a “no.”

Remember to always give the 5 key messages:

1. Explain what vaccine(s) is to be given and what it is for (in a clear way the mother understands).

2. Explain about possible side effects and how to treat them. 3. Tell the place and time of the next immunization. 4. Bring the child for immunization even if he/she is ill. 5. Safeguard the immunization cards and always bring it to the service point.

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Figure 2

Communication “Checklist” for Immunization Sessions

Greet the mother and congratulate the mother for brining in her child—and let her know you mean this.

Ask the mother for the child’s health card:

- If the mother has a card: - Thank the mother for brining the card and remind her that it is valuable and should be

brought at each visit - Check the child’s health card to see which immunizations he or she should receive during

the visit

- If the mother has no card: - Do not scold a mother for not having a card. - Issue the mother a new card and tick off the immunizations that she reports the child. - Explain that the card is valuable, should be kept safe, and brought to each visit.

Always explain to mothers the disease that this vaccine will prevent. Encourage them to ask questions.

Address concerns about immunization immediately by correcting any misconceptions. For

example, if a woman believes false rumors that a vaccine is a contraceptive she will not care about anything else you have to say. Talk to her about this first.

Explain possible side effects and how to manage them. If the mother knows to expect side

effects—for example a slight fever from DPT—she will not be frightened by the child’s discomfort and will more likely return for the next immunization.

Encourage the mother to bring her child to complete the full series of vaccinations before her

child’s first birthday so that her child will be protected against 6 dangerous diseases and will receive a “vaccination diploma” (see Annex 2)

Tell the parent when and where to go to receive the infant’s next immunization and vitamin A

supplement.

Check for understanding! Ask the mother when she will return for the next immunization session.

Enquire whether and when the mother has received tetanus toxoid (TT) vaccine to protect herself and her future newborn babies from tetanus.

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4. Involving communities in the planning of immunization services

4.1 Key activities health workers can undertake with community members Historically, social mobilization has been used more frequently to build support for campaigns than for routine immunization, but it is needed for both. Strengthening the link between community and services can only be achieved through the involvement and effective empowerment of community in the management of the services. The following actions will help create awareness, stimulate demand, help convince those that are hard to reach and encourage community participation:

• Sensitize key opinion leaders about immunizations (such as religious and community leaders) in the community in order to gain their cooperation, support and participation of their communities in supporting immunization services.

• Hold regular community meetings, share progress, and use community feedback to

improve activities: set objectives to be achieved when addressing; Iidentify problems and obstacles to achieving the objective(s); have community members propose specific solutions to the problems identified.

• Use existing community structures for communication about immunizations (e.g.

religious groups, community-based organizations) • Establish and work with community focal persons (community health promoters,

community-based health workers, religious and social groups) at district and facility levels, to inform the community of immunization activities, identify newborns, and track defaulters.

• Conduct training for health workers and community educators to strengthen their

interpersonal communication skills, ensure proper information is given, and motivate them to improve delivery of services.

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Case Study: The new outreach site Sr. Senait, the energetic new director of Guba Health Center, has agreed with the District supervisor to raise immunization coverage by 20 % in her first six months in the job. One of the things she plans to do is to increase the number of outreach sites. She makes a big calendar to put on the wall of the healthy centre, showing the days and locations of the outreach sessions. One week before the first outreach session in Kufe kebele, Senait visits the place for the first time. She sees the community leaders and tells them about the immunization program. She says that a team will come the following Tuesday at 8.00 am to give immunizations and she asks the community leaders to notify people and arrange a site. When the team arrives the next Tuesday there are no tables, chairs or water, and no clients. The team members are disappointed and the community leaders wonder what has gone wrong. Discussion 1. What do you think has happened and how could Senait have prevented it? 2. What can the team do while in Kufe kebele?

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4.2 Community promotion of immunization Community involvement is a major ingredient in the process of providing health messages to the people. Apart from being the receiver of health messages, members of the community can for example, channel health information to families, associations and other community groups as follows: Table 2. Community promotion approaches

When How Who Community meetings

Attend/conduct community meetings to raise awareness about immunizations and the current situation in the community (barriers to improved coverage, opportunities for better coordination)

• Kebele Health Committee • Religious Leaders • Health Workers • HEP Agents • Community Health

Promoters, CBRHA’s, CHAs, etc.

Market days and festivals

Conduct dramas for the community to inform them of the importance of immunizations and time and place of immunizations

• HEP Agents • Community Health

Promoters • Health Workers • Youth Groups

Religious/Social events (at mosques and churches, “Idir”, “Ekub”, and coffee ceremonies)

Talk about the importance of immunizing children and clarify misconceptions.

• Religious Leaders • HEP Agents • Community Health

Promoters Immunization Day

Notify the community in advance that immunization services will be held on a certain day (A few days in advance, every day up to the day of immunization, and on the actual day)

• Traditional Announcers • Community Health

Promoters • Youth Groups

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4.3 Identifying newborns, “left-outs” (unreached), and tracking drop-outs: In addition to communicating messages about immunization, key community members can also help increase the number of children immunized by tracking defaulters. Community health promoters (CHPs) can help Health Extension Package (HEP) agents identify and list the children under one year of age in the kebele as well as the vaccinations they have received. By identifying children who have not been immunized in their neighborhood (sub-kebele), CHPs can encourage parents to bring their children to immunizations and complete the full series of immunizations before their child’s first birthday. A sample of a tool to help community volunteers identify and track drop-outs in their communities is included in Annex 2. Case Study: Outreach in Wanja Kebele Nurse Hiwot arrives in Wanja kebele for an outreach session. Hiwot notices that only a few mothers have come for immunization. While she prepares for the session, a few more mothers arrive. She vaccinates those few children who are around. She then eats a bit of lunch that she has brought and waits for about another hour. As no more mothers come, she packs up her things and goes back to the health center. “What could Hiwot have done so that more mothers would have brought their children to the immunization session?” “What can health workers always do when they arrive at the outreach site so that mothers know they have arrived?”

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Figure 3

Who are community health promoters? The rationale behind having Community Health Promoters (CHPs) is the need for communities to take action to raise the quality of health services and improve the health of families in the SNNPR. Much can be done at home by parents who are informed about what actions need to be undertaken to take better care of their families. CHPs learn about simple actions they can take to protect their health and their family's health. They then share the key health actions with their friends and neighbors. CHPs are not intended to replace existing or upcoming categories of community health workers or activities. With one promoter per 50 households, CHPs are thought to add momentum to existing services and amplify the actions of health extension agents by mobilizing the community for improved health. Who are community health promoters?

♦ Active community members who volunteer their time to communicate key health messages (e.g., about immunizations) with friends and neighbors.

Why be a community health promoter (CHP)?

♦ CHPs learn about simple actions they can take to protect their health and their family's health

How do community health promoters work?

♦ Undertaking health actions in their own home first ♦ Talking to friends and neighbors ♦ Discussing health issues at social gatherings and religious ceremonies ♦ Mobilizing the community to use outreach services ♦ Conducting dramas on market days and festivals

How can CHPs reduce the risk to the community from vaccine preventable diseases?

♦ Undertaking an annual census of newborns who will need to be tracked to begin and complete vaccinations (1 CHP per 50 households = annual tracking of about 20 children)

♦ Mobilize households to attend fixed health facility and outreach sessions. ♦ Share names of newborns with health workers to be included in the vaccination

register ♦ Help track defaulters

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Annex 1 Mothers’ Concerns about Immunization 1. “Are the childhood diseases not part of the normal process of a child’s development? Why

should I prevent this by having the baby immunized?”

• Some people believe that childhood diseases are a normal part of growing up, because in the days of our grand-parents, when immunization was not available, these diseases were much more common.

• What many people do not realize, however, is that before immunization was available, many more children died or were crippled by vaccine preventable diseases.

• Even today, some children who are not fully immunized die from these diseases, are maimed, crippled, made blind or deaf and are weakened for life.

• This is disheartening because this suffering could be prevented by immunization. 2. “What are these so-called childhood diseases?”

• Measles is a very serious disease of childhood, which is characterized by rash and high fever. It reduces children’s resistance to illness and makes them more likely to die when they are attacked by other diseases or faced with harsh conditions that take advantage of weakened children.

• Tetanus is another very serious disease that affects both children and adults. Neonatal tetanus kills many babies during their first month of life. Newborns who are unprotected by immunization are very susceptible because the tetanus germs enter through the umbilical cord stump during or shortly after childbirth. Such babies with tetanus often stop sucking. They become stiff, have severe muscle spasms and usually die.

• Poliomyelitis (polio) is a disease that kills many children. It leaves many children

crippled (lame). For instance, many of the crippled children that are begging for alms on streets are victims of polio.

• Whooping cough (pertussis) is a disease (related to breathing) known by the loud

“whoop” that children with the disease make when they cough and vomit. Small children are more likely to choke than whoop.

• Diphtheria and Tuberculosis are the other two dangerous infections that may affect

children. Diphtheria usually affects the breathing system while tuberculosis causes a long standing cough and weight loss.

3. “Why should I bring my baby for measles vaccination? After all, measles is a common

childhood disease, which children normally recover from.

• It is true that measles is a common childhood disease and almost every child gets measles if not immunized.

• It is a serious disease. • In fact, measles kills more children than any of the other diseases that immunization can

prevent.

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What happens is this: • Infants may appear to have recovered from the fever, and the rash may appear to have

disappeared, but the ill effects of measles can continue unseen for as long as a year. • Measles weakens the child’s immunity so much that he/she is more likely to get

bronchitis, pneumonia, diarrhea, or even blindness. • In some cases, measles infections can also cause brain damage. • These complications are more common and more serious in malnourished children. • Since malnutrition is a widespread problem, measles vaccination is very necessary for

every child. • Children recover better from measles if they were given Vitamin A.

4. “I have seen some children affected by measles before the age of about 9 months when the

immunization is supposed to be given. If so, when should I bring my child for measles immunization?”

• Babies receive natural protection against measles when in the mothers’ womb and for

almost the first six months of life. • If the measles immunization is given before the baby is 9 months old, the natural

protection received from the mother may interfere with the immunization, so the vaccine will not be very effective.

• Protection obtained from mothers’ womb becomes insufficient to prevent measles when they are about 9 months old.

• Hence, 9 months is the best age to give the measles immunization. There are two possible explanations for cases of “measles” that occur before the age of 9 months: • Many of these cases are probably not measles, but are other rash diseases that resemble

measles. This is why health workers are instructed to give the measles immunization at 9 months even if the mother believes the baby already had measles.

• The second explanation is that a few of the babies really do get measles before 9 months,

because the protection from their mothers’ womb wears off earlier. But there is no way of knowing the children that belong to this group. So to be on the safe side, it is best to give the vaccine at 9 months.

Health workers should stress to mothers: • The great importance of bringing their babies for measles immunization as soon as they

are 9 months old, even if the mothers think their babies may already have had measles.

5. “Some children still have measles after getting the measles vaccine. Of what value is such immunization?

• Although the great majority of children do respond to measles immunization and are fully

protected, it is also true that a small number of children who receive measles vaccine still get the disease afterwards.

• Measles immunization offers excellent protection against contracting the disease. • The protection offered by a vaccine varies slightly among individual children for the

following possible reasons:

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- If the child is not well fed, his resistance will be lower and he may contract the disease.

- If the child is immunocompromised (lowered resistance to infections) from diseases such as tuberculosis, HIV/AIDS, diabetes.

- If the child has Vitamin A deficiency. • It is extremely important to note that the measles cases in immunized children are much

more likely to be milder. So those few children who are immunized but still get the disease still receive a tremendous benefit from the immunization.

6. “My baby received the immunization in the thigh two times, but still had one of the diseases

that the immunization was supposed to prevent. How is this possible?”

• It is a pity that this child still had the disease despite mother’s good efforts to get her immunized. The reason for this was that she didn’t bring the baby back for the third dose of the vaccine (DPT or HB).

• For a child to have a full protection it is necessary for the child to complete the three doses of DPT and HB.

• The immunizations for tuberculosis, yellow fever and measles require only one dose. • For oral polio vaccine, three doses are normally sufficient while four doses are

recommended in order to have higher protection. 7. “My husband refused to let me bring the baby back for more immunization because the

last time the baby received one dose of immunization, the baby fell sick.” • It is true that sometimes a baby develops a mild temperature after receiving a vaccine.

This is a “side effect” of immunization rather than a real sickness. • Side effects are milder and much safer than an actual attack of the diseases that

immunization prevents. • Almost all side effects will disappear in a short time. • You may want to make your baby more comfortable by giving the baby tepid baths or

paracetamol to bring down the temperature. Note: This mother should tell her husband that the health workers have explained to her that

mild fever is normal and not harmful to the child. She could also bring in her husband to the clinic for health education.

8. After my friend’s new baby was given the first injection in the upper arm, the baby

developed a small sore at the site of the injection. Is this something to worry about?

• The sore should not be a cause for worry. This is a normal reaction after the BCG injection for tuberculosis.

• It shows that the vaccine is actively working to protect the baby against the disease. • About 2-4 weeks after the injection, a small lump appears at the site of the injection. • The mother should leave the lump alone, keep it dry and should not dress it. • The lump may later break into a small sore with a little discharge. When it heals it will

leave a small, depressed scar. • However, if the discharge continues without the sore drying up, the health worker should

be consulted.

9. “I didn’t bring my baby for the immunization appointment because he had diarrhea.” • Immunizing a child who is slightly ill will not harm the child and will not make the

illness worse.

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• In fact, the weak condition of a child who is malnourished or ill with cough, cold, diarrhea, or fever makes him/her particularly vulnerable to disease.

• Immunization is therefore very urgent and important in sick children. So if a baby is not well, the baby should still be taken for immunization.

Note:

- The health worker should postpone immunization only when he observes that a sickness is so serious as to require the baby’s admission to the hospital.

- The Federal Ministry of Health and the World Health Organization recommend that immunization should not be postponed because of minor illnesses.

- Health workers should encourage mothers to keep their immunization appointment even if their children are sick.

- Mothers should understand that it is the health worker who should decide if the baby is too sick for immunization.

10. “You said that the baby’s immunization should start at birth. Since I couldn’t bring the

baby at birth, can I still bring him for immunization later?”

• Yes this mother should still bring the baby for vaccination as soon as possible. • The health worker should appreciate that, while it is best to follow the ideal immunization

schedule, on no account should the baby be denied complete vaccinations. • Even if the baby is brought later to begin immunization, the baby should still receive all

the vaccinations. • Inform the client/parent that:

- Every effort must be made to complete full immunization before the baby is one year old when he/she is still very vulnerable to the vaccine preventable diseases.

11. “What should I do if I miss my child’s immunization appointment?”

• This mother should be encouraged to come to the health facility on the next immunization

day. • If a mother misses the baby’s immunization appointment but brings the baby for

immunization on a later day, the health worker should: - not reprimand or abuse the mother, - praise her because she still keeps the appointment of her baby, even though late, and - Encourage the mother to keep future appointments.

Note:

- A child will be “fully protected” after the completion of all immunization - It is very important for parents to bring their babies for vaccination as close as

possible to the correct time, and - Health workers should make sure that all the vaccinations are given as soon as the

babies are due to receive them.

12. “My cousin’s baby is ten months old and has never received any vaccination. What vaccine can she receive if she is brought to the health facility?”

• A baby over nine months old can safely be given one dose of each of the vaccines at the

appropriate sites on the same visit. • This baby can therefore be given the following vaccines: BCG, DPT, OPV, HB and

measles vaccines. • One month later, the second dose of DPT, HB vaccine and OPV can be given, • The third dose of the same vaccines can be given a month after that.

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• You don’t have to keep measles vaccine to be the last to be received. As long as the baby is 9 months old, he can get the measles vaccine.

13. “I don’t think I will continue to visit the clinic for immunization because the last time I

visited there, I wasted the whole day” This mother may have been delayed, but wasting “a whole day” may be far from the truth.

But it is true that mothers may wait too long in some clinics to have their babies immunized. Health staff recognize this problem and recommend the following guidelines for all health workers:

• Be prompt, so that mothers can go home on time. • Register and administer the vaccines strictly on “first come, first served” basis. Your

acquaintances should take their turns like everyone else. • Do not chat with colleagues and friends while mothers wait. • During screening and checking of vaccination cards, do not make mothers look stupid,

ignorant, or careless. Be supportive if a mother forgets or loses her card. • Always be friendly. • Always avoid unpleasant remarks.

14. “I know the nurse is trying to do a good job, but the health talks are a bit boring after hearing them several times without end”.

In the past, some health talks have been too long or too difficult for mothers to understand.

However, health talks contain information that is extremely important for the families’ health. Therefore the following are some suggestions to make the talks more interesting and effective:

• Mothers have come to a health clinic not to a classroom. Make the health “talk” much

more of a health “discussion.” Encourage mothers to ask questions and to answer questions that other mothers raise.

• Let mothers comment, listen to their personal experiences, and let them realize that you also wish to learn from them.

• Encourage them to share their ideas by asking questions. • In giving information, remember that mothers are responsible adults who have been

providing for families, even though they may be illiterate. Use local proverbs, idioms, and even prayers to make health talks more interesting.

• Involve as many members of the group as possible in the discussion. • Allow group members to give their own solutions to problems. • Use stories, skits, songs, and visual aids for to draw the group’s attention and make

learning fun and interesting.

15. “Some time ago, when I visited the clinic, I forgot my child’s immunization card at home.

The health worker was angry with me.” This health worker was probably expressing the importance of the child’s health record. She

wants to see that children are healthy and growing without problem. But she should never embarrass or abuse a mother. The health worker needs to find a way to show how important the card is in a friendly way.

The card tells mothers and health workers:

• The vaccines that the child has already received and the time he/she received them • The date of the next appointment when vaccines will be due and given

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Note:

- The child health card is very important, it should be kept like a birth certificate - Mothers should be encouraged to keep it safe and clean. - Mothers should always bring it when they come to the clinic for immunization and

other visits.

16. “I stopped bringing my child for immunization because my husband refused to support me with transport money.”

• The responsibilities of caring for the child rest on both the father and the mother. • The innocent child depends on both of them for security, growth, and development. • Protection against diseases through immunization is every child’s birth right just as the

provision of food, shelter, clothing, care, and education. • If the mother reminds daddy of his role as stated above and he still does nothing about it,

she should do all in her power to set some money aside for transportation for the sake of her child. This will make - the mother happy in future. - the child healthy and happy.

Note: Immunization is a symbol of parental care and love for children. Therefore, fathers should give all moral, material, and financial support, to their wives in order to get their children immunized. 17. I have already brought my baby for three immunization visits. Isn’t that enough to protect

him?” • Three visits are not enough to fully protect a child unless the baby started the

immunization when he was much older than recommended. • For babies who follow the recommended schedule immediately after birth, complete

protection from vaccine-preventable diseases requires five visits.

18. “Why do the health workers give me the tetanus toxoid injection when they say it is for the protection of the baby?”

• Many things that affect the mother during pregnancy affect the baby also. • Therefore, the tetanus toxoid vaccine given to the mother protects her from this terrible

disease and also protects her newborn baby. • Women need to receive five properly spaced tetanus toxoid injections to ensure full

protection for her and her babies throughout her childbearing years. 19. My husband says that diseases are from God and so giving my child immunization to

prevent them is like playing God. Is it true?

• Diseases are caused by germs. • Germs are found in the environment and carried by water, air and soil which the child is

always in contact with. • When these germs attack the child’s system, she or he falls sick. • When the child takes these vaccines, the body’s ability to defend itself against these

germs is enhanced. • It is therefore very important that we keep our environment clean always and take our

children for immunization.

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20. We are told that vaccines contain some prohibited materials. Why should I allow my child

to receive such vaccines?

• Vaccines are not made from prohibited materials. • Vaccines are derived mainly from germs that cause the diseases, but which are no longer

harmful to the child • A child that is not immunized is exposed to getting deadly vaccine preventable diseases. • To ensure that vaccines remain sterile, potent and safe, they require very small amounts

of some chemicals which have been found to be safe • Vaccines are tested and proven to be safe for your child • The benefit of vaccination heavily outweighs any

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Annex 2 EPI Invitation Leaflet & Immunization Diploma Invitation cards: community volunteers will use these cards to remind friends and neighbors to begin and continue the vaccination series.

• Simple reminders • Action based • Picture tells the story • Easy entry point for

discussion • Focuses counseling on key

messages

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Vaccination Diploma

• Simple message that helps reduce drop-out: “keep coming back until you receive your diploma”

• Caretakers know they have finished the full series of immunizations when they receive the diploma.

• Health workers can show this when infants < 9 months receive DPT3 to encourage caretakers to return for the measles immunization.

• Congratulates parents for fully vaccinating their child by first birthday • Proud parents become spontaneous promoters by displaying the certificate in their

home and telling others that their child has earned a diploma for being fully vaccinated by one year of age.

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Annex 3 “My village is my home”

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