soc mob for ri final
TRANSCRIPT
Social Mobilization Strategy for Routine Immunization in Bihar –
“More than just posters”
Background and Introduction
The routine immunization system in Bihar needs strengthening. Much
remains to be done if the impact of immunization on the health of the child is
to be realized. More than half of the children who begin their immunization
series drop out before completion due to problems in supplies reaching the
delivery points, awareness, demand and quality of services. Compounding
this is poor infrastructure in relation to manpower and lack of training on
clinical as well as managerial and communication / mobilization skills that
lead to infants not receiving the vaccination as per schedule. Added to these
is the lack of accurate routine data to identify problems and target
contextually appropriate solutions. The need to bolster routine immunization
is being more widely recognized now.
Along with a focus on the operations front, i.e. ensuring supplies of vaccines
and syringes, maintenance of cold chain, deployment of health care providers
etc, it would also be crucial to focus on the social mobilization aspects of the
programme. Stakeholders as well as beneficiaries would need to be informed
and mobilized to support as well as benefit from the programme. The
immunization figures which were at 11% have now increased to around 24%
since the revival of routine immunization in the state in August 2005. This
would be further stepped up to 80% by end 2007 through improved
operations along with effective as well as targeted social mobilization.
Social Mobilization has a very important role to play in bringing stakeholders
together, developing realistic and effective plans of action and helping
communities realize the benefits accruing from investing in immunization of
children keeping in mind the barriers and variables related to infrastructure
and socio-cultural traditions and beliefs. The task becomes much more
difficult if no immediate tangible benefit is being offered or is visible to the
communities and the mobilization is expected to be effective enough to
surpass all kind of barriers.
The social mobilization would need to be “Evidence Driven” i.e. there would
need to be sufficient body of evidence to be able to successfully link activities
/ interventions to outputs as well as outcomes and results. UNICEF experience
in the area of social mobilization for polio eradication has been able to
demonstrate just that. Through targeted interventions and activities, the
UNICEF social mobilization network has been able to effect positive changes
in behaviors through the polio eradication programme. Advocacy with media,
celebrities as well as policy makers has provided the enabling environment
for the programme, whereas mobilization through community level partners
and influencers has helped in reducing refusals, drop-outs and increasing
overall faith and conviction about the programme in the minds of programme
beneficiaries.
UNICEF is supporting the routine immunization programme in the state. A two
pronged strategy would be adopted. One the one hand, UNICEF would be
supporting strategic social mobilization interventions at the state level that
would have a bearing on routine immunization throughout the state. This
would be mainly through the mass media and influencing policy. Further,
UNICEF would provide more focused and targeted social mobilization support
in ten selected districts. Nine districts would be chosen from each region and
one would be the convergent district of Vaishali. This paper attempts to
provide a framework for a social mobilization strategy related to the same.
Problem Analysis
Findings from the coverage evaluation survey and field visits provided
valuable insights into the issue at hand.
Coverage Levels were significantly higher for boys as compared to girls with
26.2% boys being fully immunized as compared to 24.5% girls. Also coverage
levels showed variations by religion, with it being significantly lower for
Muslims as compared to Hindus with 27.2% Hindu children being immunized
as compared to 17.7% Muslims. Similarly, coverage levels were significantly
lower for SCs at 12.6% as compared to other caste groups at 30.1%.
Importantly, coverage levels showed significant improvements with socio-
economic status of the households and literacy of the mother.
Social exclusion issues were an area of concern. There was an acute
‘provider bias’ in relation to people from socially excluded communities.
Problems always seemed to be identified by the providers among ‘Harijan
tolas’. Providers were found reluctant to do outreach in these areas. The
behavior meted out by providers to beneficiaries coming to the centre from
these areas also deterred them from doing so.
It had been observed that in about 37% of the cases in urban and 33% in
rural help was received from the husband in getting the infant immunized.
Further, in about one-third cases help was also received from other family
members, mainly elderly women. The help received was generally
accompanying the mother or taking the child for immunization. Lack of
support for mothers wanting to immunize their children was reported. Often,
husbands, mother –in-laws and secondary audiences were found to be
discouraging mothers from immunizing their children as they felt it was
unnecessary. The common explanation from in-laws being “This was not
required for our children, so why now?”. Thus reaching out to the
‘gatekeepers’ i.e. people who have an influence on the way primary
audiences for communication behave would be of prime importance so that
they get an enabling environment to sustain the change in their behaviors.
The main reasons for non-immunization both in rural and urban areas
reported was lack of awareness (did not know about vaccination, did not
understand benefit of vaccination, immunization schedule), lack of motivation
(aware of the need and the facility but do not use services because of not
getting time and perception that child is too young and child was ill). In some
cases non-availability of vaccines was also a reason. Immunization was
quoted to be a low priority among people with the perceived benefits not
being clear. Lack of time to take children to the health centre due to
engagement with household chores as well as livelihood was mentioned
often. Some people could only say that “It is good for our children’, but could
not explain the exact benefits.
Only 23% mothers in urban and 13% in rural areas were aware of various
vaccines that an infant should get along with the age at which each is given.
However, those who were aware mentioned vaccination as very important,
about which they had known through discussion with health staff. Those who
were aware and answered mentioned that vaccination for children was very
important. Further, mothers who answered that they had discussion with
health staff, majority reported that health staff discussed with them about the
importance of getting children immunized. It was observed that the coverage
levels were higher for those who were informed of the benefits by the health
functionaries reinforcing the need of orienting the health and other frontline
functionaries on communication and mobilization skills.
In many places, the caregivers were of the opinion that the child is ‘too
young’ for immunization, reinforcing the need to inform caregivers about the
correct age for each vaccine.
The normal reactions following immunization and lack of counseling by the
providers related to the same was found to be another reason for drop-outs.
No major myths or misconceptions were found related to immunization.
Deaths following immunization due to other unrelated reasons however, were
linked to immunization and had sometimes sparked refusals and resistance in
some areas. However it was found that there is a wrong perception in the
community that if the child gets required pulse polio drops, he/she is fully
immunized for all diseases.
About 38% from rural areas were aware of the routine immunization sessions
held in their village; also 29% in urban areas reported that immunization
sessions were held in their place. About 40% from rural areas reported that
immunization sessions were held in their village. Also, about 30% in urban
areas reported that immunization sessions were held at their place. It was
reported that these were held generally at the ICDS centre. Over 95%
reported that the sessions were held at the same place and reported that the
place for immunization sessions was convenient. It was reported that these
sessions were held monthly or weekly at the same place.
In relation to the general health seeking behaviors, both in rural and urban
areas majority reported as going to Private Doctors. Only about 9% in rural
and 20% in urban reported as going to Govt. Health facility. It was found that
many people belonging to higher castes go to private practitioners for
immunizing their children. People from lower castes often do not attend
because of the treatment meted out to them by the providers and people of
higher castes at the centers.
Reasons for not immunizing children
Reasons* Rural Urban
Did not know about vaccination
Did not understand benefit of vaccination
Doctor/Health worker said it was not
necessary
Doctor/health worker advised against it
Did not know where to get immunization
Vaccine was not available
Child got sick after he/she got vaccination
Can not afford its cost
Fear of side effects
Fear of getting disease
Child was ill
Could not get time to go for vaccination
Was discouraged by family members
Against religion
Child was away
Child is too young
Others
24.3
17.0
1.5
1.5
8.5
8.3
2.1
8.3
3.7
1.0
1.1
6.5
12.9
7.2
0.3
0.9
25.1
3.2
20.9
13.7
2.6
0.9
2.0
3.7
2.9
6.3
4.6
4.3
6.6
15.1
4.0
2.6
0.6
9.7
12.0
2.6
N 1575 350
About 47% of households in rural areas and 54% in urban areas reported
having immunization cards. Communication would need to focus on the
importance of the same as it is an important tool for tracking service delivery
as well as receipt.
The following table lists perceptions of problems faced by communities
related to immunization.
Item Rural Urban
Facing problem
Yes
No
46.5
53.5
33.5
66.5
1996 647
Type of problems faced
Services not accessible when required
Fear of side effects
Quality of service is poor
Do not know vaccines, what vaccines are
needed and when
Do not know where to take child for
immunization
Vaccines are not available in the village
Vaccines are not available at health centre
Too far to take the child
Do not have time to take child for
immunization
Cannot afford the cost
Behavior of health worker is not good
Others
8.3
8.9
15.4
14.4
16.9
22.0
12.6
19.5
7.6
11.5
3.4
9.8
7.8
24.5
12.0
14.2
6.1
10.7
10.6
5.0
10.6
17.4
1.3
11.9
928 217
Information had been collected from those who availed immunization
services about their opinion regarding non-utilization of routine immunization
services by others. According to them not aware of the need and fear of side
effects were the main reasons for non-utilization of routine immunization
services by others.
Opinion Rural Urban
Not aware of the need
Difficult to reach the place
Adverse rumors
Fear of side effects
Others/Don’t Know
35.4
5.1
3.6
22.5
33.4
34.8
3.2
4.7
25.7
31.6
954 342
The main source of information for routine immunization reported was
Radio/TV, Health worker (ANM/AWW/LHV), Husband, Family members as well
as neighbors and friends. In urban areas Private doctor was also reported as
important source. The most preferred source of information on immunization
reported was Radio/TV/Family members and health staff, which is in line with
the source currently providing the information.
ItemRural Urban
Aware
Not Aware
12.9
87.1
23.3
76.7
1996 647
Source of Awareness
ANM/AWW/LHV
Govt. Doctor/Health Worker
Private Doctor
Social/NGO Worker
Radio/TV
Billboards, Posters at health
centres, booklets, news papers, etc
Husband/Family member
Traditional birth attendant
Pharmacist
Friends/Neighbours
Others
26.1
21.0
17.1
5.8
53.3
3.9
20.6
2.7
-
21.8
1.1
29.1
25.1
26.5
2.0
70.8
6.6
25.1
1.3
-
19.2
3.3
N 257 151
Preferred sources of information
ANM/AWW/LHV/Health Worker
Doctor
Social/NGO Worker
Radio/TV
Billboards, Posters at health
centres, booklets, news papers, etc
Husband/Family member
Traditional birth attendant
Pharmacist
Friends/Neighbors
34.2
33.5
5.4
98.4
2.3
35.0
-
-
26.8
27.8
42.4
8.6
98.7
11.9
33.1
-
-
19.9
257 151
Behavioral Analysis
The target audiences have been following certain practices since ages, which
have become a way of life for them over the years. Thus changing them is a
challenging task. Constantly asking the target audiences to perform ‘clinically
appropriate’ behaviors has often alienated target audiences from
communication. Just asking the audiences to accept a behaviour that is
‘appropriate’ according to prescribed standards will not help as behaviors are
closely linked to the environment that a person lives in. Based on the barriers
that exist, a ‘feasible’ or doable behaviour has to be suggested. Along with
the provision of messages to the target audience, there is a need to also
provide an enabling environment to help the audiences sustain the change in
behaviors. This is to be achieved by reaching out to the secondary target
audiences who influence the behaviour of target audiences. It is important to
remember that more often than not, people do things or behave in ways that
are acceptable or considered appropriate by people in their community.
Therefore reaching out to secondary audiences or ’gatekeepers’ assumes
great importance.
Health related behaviors are affected by multiple levels of influence.
Individual factors such as knowledge, attitudes and personal experiences;
Interpersonal factors such as family, peer group; Community factors such as
social networks, community norms and Institutional or Policy factors. Thus,
taking account of these levels of influence would be crucial.
It is extremely important to understand as to what is ‘of value’ to the target
audiences. What has maximum influence on their behaviour? Most
importantly, what is it that makes them do what they do? Most behaviors
have a perceived rationale or logic behind them. Unless social mobilization
attempts to analyze and address the same it would not be effective. There is
often a perception that most things happen, or are they way they are
because they are destined so. The connect between little things such as
immunization that can be done at the individual / household level and larger
changes is absent. There is also a feeling that all development is to be done
by the government and the individual or community has hardly any role /
capacity related to the same.
There is lack of awareness about the importance as well as misconceptions
related to immunization. Low motivation to change behaviors arises from the
lack of knowledge regarding benefits related to practicing the same and
social conditioning. The community environment is also not supportive
towards the practice of immunization as perceived benefits are not clear. The
service providers lack the required communication and mobilization skills in
order to convince families, effectively address their curiosities, ally their fears
and put concerns at rest. Inadequate counseling on side-effects of
immunization also often leads to cases of drop-outs. Sporadic service
delivery, distance from delivery points and non-addressal of community
demands often also leads to alienation from health services.
Participant Analysis
In order that social mobilization is effective, it should be relevant to the
participant groups. Therefore it is important to analyze the characteristics of
the participant groups and find out how each group can maintain the practice
of desired behaviors. Different strategies, messages and channels will be
needed to address each group.
A. Primary Participants
Since the focus of mobilization is on increasing household awareness,
sensitization and motivation to ensure complete immunization, three primary
participants have been identified. They would be reached out to, using all
channels ranging from interpersonal to mass media.
1) Mothers (including pregnant women) - The mother appears to be an
important participant going by the task at hand. The mother plays an
important role in looking after children and spends a major portion of her
time doing the same. Further, the issues related to looking after children is
traditionally within the domain of a woman’s responsibility. Hence, there will
be a need to speak to the woman in the household. While she may have
limited decision making power but can be a major influencer provided she
understands the need of immunizing her child.
2) Father / Head of the household – Traditionally, he maintains a distance
from household and child rearing activities, but is an important participant as
he is the decision-maker in the household; almost all things are done post his
approval. Hence he needs to be sensitized towards the need for
immunization.
3) Mother – in – law / Other caregivers – As a senior lady of the household,
she usually holds great influence over household and child rearing activities.
She is seen as someone who has great experience in the area and often
takes important decisions related to the same. Thus reaching out to her and
sensitizing her about the need for immunization would greatly help the
mother in practicing the same.
B. Secondary Participants
Although the primary participants and the focus will be the mother,
husband /head of the household and the mother-in-law, this strategy also has
the potential to generate awareness and change related to the issues in the
minds of the following important secondary audiences:
1) AWWs /ANMs/ASHAs – These are frontline functionaries who come in direct
contact with mothers and families and thus need to be reached out to and
oriented on skills and issues for effectively engaging with families.
2) The community - including Village Level Communicators /Self-help groups,
PRI / Village health committee members, rural medical practitioners,
practitioners of alternative systems of medicine, NGOs etc are the facilitators
and opinion makers, who are usually more informed and socially conscious.
These people can exert peer pressure as well as be role models for the
unaware and non- forth coming population. They would be systematically
engaged with and oriented so that they are better equipped to support
primary participants.
3) ‘Positive Deviants’ – Mothers and families which exhibit positive behavior
in relation to immunization, could be used as ‘role models’ in the community
and ‘recruited’ to convince other families in their respective areas.
C. Tertiary Participants
1) Health and nutrition supervisors, managers and professional staff at sub-
centers, PHCs, district hospitals; members of local professional organizations
and institutes - These participants are important as they are responsible for
the programme implementation at their levels and also help in creating a
favorable atmosphere for behavioral change to take place.
2) The Government including the various program administrators and policy
makers at state and district levels – Constant advocacy with this group would
be required in order to influence favorable policy for the programme.
3) Media and Celebrities – This segment has a tremendous impact in
informing and guiding decisions of programme beneficiaries as they are seen
as reliable and credible source of information.
Channel Analysis
The channels selected depend on both the target audiences that have to be
reached out to as well as the message content. Typically, an assortment of
channels are used in order to reach out to target participants for maximum
impact. Getting the correct ‘media mix’ is of crucial importance.
Mass Media
Audio Visual mass media is an effective way of reaching out to a large
number of people. It has great mass appeal as it is seen as a credible means
of information and entertainment by millions. It brings thoughts alive through
pictures and images and creates aspirational values in the minds of viewers.
It has great power in bringing about awareness on issues. However, weak
programming can often cause serious miscommunication.
The print media also has great reach, but is restricted to literate segments of
the target audiences. It is also seen as a credible source of information by
millions. In the context of Bihar where electrification is extremely low, TV
might not be the most appropriate medium. However, radio would definitely
be a medium of choice.
Folk Media
Folk media has great acceptance among target audiences and can be greatly
tailored to suit programme / audience needs. This is a medium which has
great potential in brining about behaviour change as the product of
communication through this form is as close to the audience as it can get. It
is great for generating discussions in the community. However, it is
extremely challenging to implement and monitor. Considering the
acceptance and potential of folk media, it would be use extensively.
Outdoor Media
Outdoor media in the form of hoardings, wall paintings etc. help in creating
visibility around the behaviour being promoted. It also acts as a constant
reminder to the target audiences. Monitoring the quality of implementation
however is often very difficult.
Interpersonal Communication
Interpersonal communication provides for two-way communication. The
target audience can get their queries and doubts addressed easily. Detailed
information can be provided which is difficult to provide through any other
channel. Literacy of the audiences is also not a bar. It has great potential in
bringing about and supporting sustained behaviour change.
The flip side is that the process is time consuming, and depends heavily on
the skills/ knowledge of the communicator. Its reach is also limited
Interpersonal communication by AWWs/ ANMs/ASHAs and other facilitators
would be key to the strategy. A great deal of interpersonal communication
activities are envisaged through them.
IEC materials
IEC materials are often not seen as a separate channel but greatly help in
communicating thoughts and ideas. Posters, Banners, Leaflets, flipcharts,
games and activities, CDs all help in attracting target audiences and creating
an enabling atmosphere.
Objectives
The overall objective of the strategy along with the increase in immunization
services coverage from the current levels of 24% to 80% by the end of 2007
would be to influence positive behavior change among communities with
respect to immunization resulting in sustained coverage and reduced drop-
outs in the long run. This would include enhancing knowledge regarding
immunization and encouraging conversion of the knowledge into practice and
ensuring that immunization is continued as per schedule. Strategic social
mobilization for immunization would meet the following broad objectives to
help achieve the programme goal of increasing immunization coverage and
reducing drop-outs:
1. Identify behavioral issues and address them in order to increase
knowledge and awareness levels to make the communities more
conscious about the issues related to immunization thus creating an
overall positive environment to facilitate community mobilization and
behavioral change.
2. Ensure that households are aware of the linkage between
immunization and child survival and development.
3. Identify key actors at all levels ranging from the individual level to the
policy level and systematically engage them.
4. Maximize the impact of social mobilization efforts at the state, district
and block level by using a multi- sectoral approach, appropriate use of
technology, strengthening coordination amongst partners and effective
advocacy for supportive policy.
5. Increase coverage by establishing and informing demand for
immunization
Components of the Strategy
A two pronged strategy would be adopted. One the one hand, UNICEF would
be supporting strategic social mobilization interventions at the state level
that would have a bearing on routine immunization throughout the state. This
would be mainly through the mass media as well as influencing policy.
Further, UNICEF would provide more focused and targeted social mobilization
support in ten selected districts. Nine districts would be chosen from each
region and one would be the convergent district of Vaishali.
The communication and mobilization activities would endeavor to raise
awareness levels, influence attitudes and beliefs at the household and
community level in support of adoption of immunization and promote
practice of complete immunization .The strategy will build on a mix of social
mobilization activities, including advocacy, behavior change communication
and community mobilization.
State – Level Strategy
While the health department has undertaken many measures to improve
immunization coverage, it has lacked priority among people. Amongst the
general public as well as people’s representatives, other social and economic
issues have taken precedence over child health. Therefore, the first step
should be to highlight immunization at various levels more prominently
among communities, implementers and the policy makers and relevant office
bearers. Political support is crucial to establish priority and commitment for
the issue and ensure favorable policy. The endorsement by the Government
would also help relevant office bearers to prioritize their plan of action.
Advocacy will play a key role in ensuring that there is a positive environment
in which the immunization programme can be implemented effectively. The
primary area for advocacy focus would be on working with partners (like
elected representatives, media, celebrities etc) who can increase visibility
and credibility for the programme.
In order to extend the reach and impact of the strategy there should be a
focused effort to bring in new partners who can increase visibility and impact.
Partnerships can be initiated and be strengthened by making efforts to
engage the partners actively in communication for immunization. The
strategy can also seek to work closely with academic and professional groups
to provide technical inputs to the programme.
Advocacy
Advocacy at the state level will play a very crucial role. The thrust of
Advocacy will be to establish the context and relevance of the cause. An
effective advocacy campaign can also get support from media and can keep
the issue alive for a longer period of time in the public domain.
Advocacy through print media
Media is poised to play a significant role in improving the status of routine
immunization in the state. The media's reach is vast, and the investments
made for advocacy through media are cost-effective. Media enjoys a high
degree of credibility with the people and can be an effective partner for
dissemination of information. Working with the media is also important from
the point of view of averting possible negative coverage, which can be
counter-productive. This is especially true in the case of routine immunization
(RI) programme which is relatively new to Bihar, having been re-launched
recently. Consequently, people sometimes attribute infant and child deaths
occurring due to various other reasons to vaccine. Some of the possible
activities for print media partnership on Routine Immunization are:
1. Preparation of quality briefing package: The starting point for media
advocacy is often a good briefing note which presents the information
correctly and with lucidity. This will help in keeping the media
community informed about Routine Immunization.
2. Workshops with District Public Relation Officers (DPROs): The Public
Relation Department has DPROs in all the districts. DPROs work closely
with the District Magistrates, Civil Surgeons and other district officials
and working with the media is their mandate. UNICEF has a state level
partnership with the PRD and is in the process of orienting PROs to
many of the issues UNICEF works for. It is proposed that DPROs are
supported in holding two media workshops in each district between
October 2006 and December 2007.
3. Media visits: In order to bridge the gap between theoretical knowledge
and ground reality, media exposure to the changing trends in routine
immunization will help in keeping them interested in the programme.
The result will be regular media coverage and media monitoring of the
programme at the ground level. It is proposed that for each district,
two to three media visits are organised between now and December
2006. It is proposed that capable NGOs are identified for organising
field visits of journalists.
4. Media Fellowships: There are many keen journalists who are willing to
take some time off, travel with a purpose, and bring back a rich haul of
stories for their newspapers. This can be made possible through media
fellowships. Media fellowships for routine immunisation, for instance,
with The Hindustan Times will involve the signing of a Memorandum of
Understanding between UNICEF and Hindustan Times. The MoU will
specify the nature of grant, the conditions governing it such as how
many days the journalist will travel for, which subject or geographic
areas he/she will cover and how many stories he/she will come back
with. The paper will be committed to publishing at least a certain
number of stories. Media fellowships can be worked out with individual
papers or in partnership with, say, the State Health Society or the
Public Relations Department. UNICEF can do it alone as well. A panel
comprising editors, UNICEF and Government of Bihar will judge
applications and award fellowships.
5. Media Awards: A media award announced for a specific subject area
leads to a spurt in activity among all newspapers. A UNICEF award to
journalists for writing about Routine Immunisation is likely to lead to
increased media interest. The awards could be announced in
partnership with the Public relations Department or State Health
Society. An award function at the state level will ba an opportunity to
discuss the importance of routine immunisation and its connection with
infant and child survival as well as recognise the work of journalists. A
panel comprising UNICEF, State Government and Editors will be
constituted to judge the awardees, which itself will strengthen the
partnership for routine immunisation and renew editors' commitment
to the programme.
Advocacy through electronic media
Television penetration in Bihar is low. In reports about television penetration,
there is always a mention of Bihar since it occupies the lowest position in
terms of television penetration. A study by a marketing company in 2000 put
the television ownership figures at 3.7 per cent, while a 2004 study showed a
negligible increase. On the other hand Radio ownership figures in Bihar are
higher*. Radio remains the only source of information for families in many
parts of Bihar, particularly rural and hard to reach areas. The role of radio as
channel for information is therefore vital.
The following activities are proposed:
1. Radio spots on Routine Immunization especially during special
campaigns.
2. An entertainment based play covering both Routine Immunization and
Polio Eradication Programme
3. Programmes focusing on immunization could be supported on radio
and television. This will help in bringing the issue in the public domain,
generating the hype and possibly creating demand. This would also
motivate the political leadership to take the issue up as a priority.
Success stories could also be broadcast in order to foster a positive
image of health care providers. News channels can be roped in to do
dedicated programming on immunization.
Advocacy through Celebrities
Celebrities add great credibility as well as visibility to any programme.
Previous experience of having used celebrities for promoting polio as well as
routine immunization have been positive. Celebrities would be particularly
useful for the launch of RI campaigns. They could also visit a few nearby sites
to monitor the activities and also give a media release to raise the profile as
well as seriousness of the programme.
Advocacy with policy makers
Mailers on the importance of immunization could be sent to the policy makers
and implementers. The mailer would reiterate the context and relevance of
the issue in the present scenario. It would also underline specific roles and
responsibilities vis-à-vis partners. Screen Savers on RI could also be
developed and installed on the computers of political leaders and decision
makers in order to buy ‘mindshare’ and assist the process of engaging them
in the issue.
Advocacy with Partners for Coalition building
Partners from all quarters such as ICDS, NGOs, INGOs, SHG networks, PRI
representatives, Religious organizations, and occupational groups such as
COMPFED etc. would need to be brought into the fold in order to help in the
process of mobilization through their state-wide networks. They could also be
utilized to support district-specific social mobilization activities.
Strategy for 9 + 1 districts
District and Block Coordinators
A nodal person would be required at the district and block level, who would
coordinate activities at the same. The person would be involved in the
Identification and training of effective local partners/ volunteers and local
motivators who come in direct contact with families and communities on a
regular basis. These could be local SHGs, youth club members, PRIs, AWWs
/ANMs etc. They would also liaise with the concerned governmental
authorities in order to improve social mobilization and communication
activities as well as advocate for improving operations. UNICEF already has
established a strong social mobilization network for polio in 22 high-risk
districts. The SMCs at the district level and BMCs at the block level in these
ten districts would support the programme. This would provide a great boost
to RI as the target audiences for both are the same and already established
local partners and systems of polio could be used for RI as well. This would
also ensure that the newborns identified during the round are give the
immunization cards and brought into the fold of RI.
Mass media campaign
The components of the state-level mass media campaign involving television,
radio and print media would also have a bearing on the selected districts.
This would be in the form of spots on radio as well as doordarshan placed
before, during and after programmes with high TRPs or listenership and
advertisements in national as well as local dailies. The same spots could also
be played on local cable TV networks.
Effective Interpersonal communication through ANMs and AWWs
The ANMs and AWWs are the cutting edge of any public health programme as
it is through them that health and nutrition services are provided to the
community. They often lack effective social mobilization and interpersonal
communication skills, because of which they are often unable to effectively
counsel and motivate families. TOTs would be done with trainers from each
district, as well as trainers from AWTCs and ANMTCs on social mobilization
and communication skills. These trainers would in turn train AWWs and ANMs.
Local volunteers and mobilizers would also require a basic orientation. Thus
the workers would be better equipped while engaging with families,
communities and local influencers alike.
Effective Interpersonal communication through Village Level
Communicators /Self-help groups, PRI / Village health committee
members, rural medical practitioners
Other channels for interpersonal communication would be explored for
promoting effective ‘parenting practices’ for child survival, with a focus on
routine immunization, so that primary audiences are exposed to the same
messages by people of their community creating an enabling environment for
sustained change in behavior.
Outdoor Media and IEC materials
The IEC materials/outdoor media will support interpersonal communication
and give credibility to the communicators. Outdoor media in the form of
hoardings at the district and state headquarters at strategic locations and
wall paintings at block / gram panchayat level would have to be put up in
order to create visibility as well as an enabling environment.
IEC Materials such as posters and banners would need to be developed and
supplied to the districts / blocks well in advance. The materials would need to
be put up according to a predetermined micro plan at strategic locations and
not on an ad hoc basis for ensuring maximum effectiveness. In the
development of outdoor media and the IEC materials, the following principles
will be followed:
Branding – All Outdoor media and IEC materials in support of the
campaign would need to follow a branding guideline i.e. all materials
should have the same ‘look and feel’. It should not seem that the
materials are not connected with each other. A brand ambassador would
help in the branding process.
Design - IEC materials should be taken as part of an entire package and
not seen on an individual stand –alone basis. The material would need to
have recall value, brand identity, and easy recognition and association
with the campaign. The materials would also need to be field tested
before production
Cinema Slides / CD Shows
Cinema slides on immunization would be developed and distributed to local
movie halls for screening. Further an agreement could be entered into with
DFP for conducting CD shows followed by community discussions on
immunization in selected areas
Community Mobilization through local partners
Community mobilization is a critical element especially where a large number
of people are not concerned about the issue and do not understand its
importance. Community meetings, Block meetings, rallies etc. will need to be
organized with the help of local partners in order to mobilize the community
in relation to the issue.
Use of Folk Media
Folk media has great acceptance among target audiences and can be greatly
tailored to suit programme / audience needs. This is a medium which has
great potential in brining about behaviour change as the product of
communication through this form is as close to the audience as it can get. It
is great for generating discussions in the community. However, it is
extremely challenging to implement and monitor on a large scale. It could be
used at select location as far as practicable in collaboration with Song and
Drama division
Promotion of RI by Village Volunteers in Vaishali
Youth volunteers in the convergent district of Vaishali are a huge force which
would be used to mobilize as well as motivate communities for routine
immunization. They would be provided a special input training on RI along
with their regular training. They would act as a link between the service
providers and the community and ensure that all children in their area
comprising of 50 households are fully immunized.
Linking with LRGs in Dular districts
The dular districts have a demonstrated, effective model for the promotion of
child health and nutrition through community volunteers called LRGs. These
LRGs would also be used in the common districts for the promotion of RI in
their areas.
ASHAs
The ASHAs being recruited under the NRHM are a powerful source for social
mobilization. There would need to be a rational selection so that underserved
communities find representation in the same as otherwise mobilizing people
from the same would be a challenging task. They would need proper training
on communication and social mobilization, if they have to function efficiently.
The block as well as district management units would focus on the same as a
priority.
‘Positive Deviance’
Mothers and families which exhibit positive behavior in relation to
immunization, would be used as ‘role models’ in the community and
‘recruited’ to convince other families in their respective areas.
Social Exclusion
Social exclusion is a phenomenon that is prevalent in the state. Unless there
is special attention given to the issue within the ambit of health
programming, the dream of immunizing all children will not turn into a reality.
There are pockets within many villages where either services do not reach
due to bias on part of the provider or community characteristics that are not
conducive to immunization. However, UNICEF experience in the area in the
context of polio eradication initiatives has taught some valuable lessons and
the same can be used for routine immunization. An intensive mapping
exercise has revealed certain pockets where socially excluded or
‘underserved’ communities exist. Special strategies have been designed to
address issues in these communities.
Conscious efforts would be made to look at all activities through the lens of
social exclusion. The following initiatives would be incorporated in the
programming:
1. Focus on immunization as a child right’s issue through the mass –
media component of the strategy
2. Forming strategic partnerships with religious, occupational and other
groups that elicit trust and credibility among socially excluded
communities and using them as advocates for the cause
3. Sensitization of frontline providers on the issue
4. Identifying social mobilizers/ partners from underserved communities
for underserved areas
5. Increasing outreach in underserved areas
6. Development of need-based local communication material and local
media activities such as street plays, mosque announcements etc.
7. Through the work of the District management units, facilitating the
inclusion of underserved community institutions, in the planning,
implementation and monitoring of immunization activities at district
and block levels.
8. Using events, festivals, religious occasions of underserved for
advocacy and mobilization
Programme Management
A well established structure as well as systems would need to be in place in
order to implement as well as constantly monitor and assess effectiveness of
communication and mobilization activities. It would help measure outputs
along with identification of ‘best practices’ as well as areas for improvement.
Communication reach as well as effectiveness in promoting health-seeking
behavior would need to be assessed.
A. Coordination of Communication and Mobilization activities
Coordination of communication activities for immunization as a part of
child health will be done by the state IEC bureau. A working group of
partners would need to be developed in order to conduct communication /
mobilization activities in a focused and concerted manner.
Similar working groups in the form of District management units would
need to be developed at the district and block levels in order to create
synergy and facilitate communication efforts.
B. Sustained Capacity Building at District and Sub-district levels
It would crucial to ensure that the capacities of the functionaries in the
above-mentioned units at the district and sub-district levels are built as well
as constantly upgraded in order to effectively manage communication and
social mobilization initiatives. Quarterly or half –yearly, need-specific capacity
building sessions would be organized at the district as well as the sub-
regional levels.
C. Monitoring and Evaluation
Sharing Workshops
Half- yearly sharing workshops would be organized at district followed by
state level, to take stock of the progress made and lessons learnt. This will
help in modifying the strategy if necessary to achieve the desired results.
Innovative ideas, which have worked, can be shared at this forum and
members can be persuaded to adopt these ideas in order to achieve optimum
results. The achievement of implementers at various levels from district to
village would be highlighted to motivate them and to persuade the non-
performers to learn from them.
Ongoing monitoring
Ongoing monitoring of activities and reporting would be done by the district
and block coordinators supported by the district as well as sub-district
management units. This would help ensure quality of processes.
Representatives from the state management team would also conduct
sample visits to programme areas.
Annual Assessments
Annual assessments would be done by external agencies in order to assess
effectiveness of activities and establish linkages with outcomes. Further,
increase in coverage, reduced drop-out’s etc. would be used as proxy
indicators.
Treatment
The recommended strategy along with reaching out to the target audiences
directly will also facilitate behavioral change among the target audiences by
impacting at various levels in the external environment creating an enabling
environment for sustained behavioral change. The audiences will be
empowered with information at a micro level. The state level mass
communication campaign will be helpful in establishing the magnitude/
seriousness of issues and thereby creating a sense of urgency for the
programme among the diverse set of audiences. At the community level not
only it will create awareness but it will also help community influentials to
persuade reluctant households. It will also motivate support institutions like
NGOs working in the areas, PRIs etc to gear up for changing the situation and
building upon the awareness created by the mass communication campaign.
At the administrative level, communication will help in attracting the
attention of relevant of office bearers associated with the project.
There would need to be some motivational triggers that will offset the desired
behavior change across the audiences and set a tone for the campaign.
Health is the trigger that is commonly used but it has not delivered the
desired result However, since health is the most common connect with
immunization, there is a strong need to establish the relationship between
the desired behaviors and the expected health outcome/benefit.
Parents would have to be shown that immunization is a ‘worthwhile, low cost
investment’ for their children and urged to move out of their fatalistic
approach to life.
It would need to be demonstrated that a fruitful, productive life of their
children is actually in their hands and does not require much investment
apart form a bit of time at regular intervals for taking their children for
immunization. There might be many problems in their lives which do not
have immediate solutions, but then why not try and start with the small
minor ones that are there in their hands and could have a long lasting
impact. It relates to just looking at things in a positive light and doing
whatever is possible to better the quality of life within the limited means.
Parents, caregivers and people in general have a strong emotional connect
with children and this very theme of emotional attachment could be used to
advantage. The trigger would focus on the lengths that parents go to for their
children. Immunization in that sense would be a small thing which parents
could ensure for the happiness of their children. Would a parent like to have a
disabled child or be directly responsible for the death of his or her child?
The mass media, outdoor and IEC component of the strategy would have a
child making a direct emotional request to its parents asking them to ensure
her survival and healthy life by immunizing her. This would motivate parents
emotionally as parents often find it difficult to refuse an emotional request
from their children. More so, to do with their welfare.
‘The child’ with a locally appropriate name and appearance would be the
mascot for the strategy, doing all the communication not just with the
parents but with diverse audiences ranging from elected representatives to
policy makers to health care providers and the like, with specific messages
for each of the target audiences.
This so called ‘brand ambassador’ would help in people identifying with the
objective of the strategy well as give visibility and emotional appeal.
The creative focus would be to develop messages around this theme.
Messages, Target Audiences and Channels of Communication
Target Audience Messages (Basic themes. Require creative
treatment)
Channels of Communication
Primary Audience
Mothers, mothers-in-law,
caregivers, husbands
/head of the household
Immunization helps in building the child’s
immunity and protects it from infections,
illnesses and even death- It is your child’s
birthright
In order to get the benefit of immunization,
all does must be given to the child as per
schedule- The immunization card is crucial
in this regard.
It is totally safe for your child and is
available free of cost
More than one vaccine can be given in one
day without causing any harm
There might be a few side-effects following
immunization- this is not a cause for worry,
but a sign that the vaccine is working. Find
out from the provider on how to deal with
the same.
It is available at X location on Y date
IPC through AWW/ANM/Village
level communicators
Wall paintings, posters, hoardings
Radio, Theatre, CD shows, cinema
slides
It is a small initiative that would go a long
way in ensuring that your children can lead
a healthy, long and productive life
Secondary Audience
AWWs, / ANMs /ASHAs
Immunization helps in building the child’s
immunity and protects it from infections,
illnesses and even death- It is every child’s
birthright.
Public health goals can never be achieved
unless all children are immunized- you have
the power to be a change agent for a
healthy, prosperous India.
Training on IPC Skills related to
the promotion of immunization
social exclusion, and visioning
Wall paintings, posters, hoardings
Radio, Theatre CD shows, cinema
slides
Secondary Audience
Village Level
Communicators /Self-
help groups, PRI /
Village health committee
members,
rural medical ractitioners
Immunization is crucial for the survival,
growth and development of children in your
community. Help in promoting the same.
Immunization helps in building the child’s
immunity and protects it from infections,
illnesses and even death- It is your child’s
birthright
In order to get the benefit of immunization,
all does must be given to the child as per
schedule- The immunization card is crucial
in this regard.
Orientation for rural medical
practitioners, SHGs, Panchayats /
leaders who interact directly with
families
Wall paintings, poster, hoardings
Radio, theatre, CD shows, cinema
slides
It is totally safe for your child and is
available free of cost
More than one vaccine can be given in one
day without causing any harm
There might be a few side-effects following
immunization- this is not a cause for worry,
but a sign that the vaccine is working. Find
out from the provider on how to deal with
the same.
It is available at X location on Y date
It is a small initiative that would go a long
way in ensuring that your children can lead
a healthy, long and productive life
Tertiary Audience
Health and nutrition
supervisors,
managers and
professional staff
at sub-centres, PHCs,
district hospitals;
members of local
professional
Continual and extensive promotion of
immunization among communities is
required to reinforce their behavior change
Increase of visibility around immunization
Promotion of immunization through public
engagements, visibility events and media
outreach
Briefings, workshops and
orientations with health and
medical associations
Advocacy materials to senior
managers, administrators and
policy /decision makers
Sharing workshops
organizations and
institutes, policy /
decision makers
Joint field visits
Media articles / coverage
Activities Matrix
Audience Expected Results Activities Timeline
2006- 2007
Risks
Q
4
Q
1
Q
2
Q
3
(Family)
Mothers,
mothers-in-
law,
caregivers
Caregivers/mothers/
mothers-in-law can explain
(knowledge) why
immunization is important
for the healthy growth and
survival of the child
Caregivers/mothers/
mothers-in-law believe
(attitude) that
immunization should be
given to the child
Provision of
messages by front-
line workers
through direct
home visits
Interpersonal
communication
and mobilization
through Village
communicators ,
X X
X
X
X
X
X
AWWs /ANMs not
available everywhere
Infrequent,
unplanned household
visits by front-line
workers
Poorest households
not reached
effectively due to
Mothers, mothers-in-law,
caregivers discuss
(intention) the importance
of immunization, and
believe not giving
immunization can be
harmful (knowledge and
attitude)
Mothers acquire skills to
initiate and maintain
immunization practice
(knowledge)
Mothers practice
immunization with aided
support from AWW or other
community health workers
(practice)
self-help groups,
NGO workers and
PRI
Local and mass
media outreach
through radio,
Song and Drama,
DFP, cinema slides,
TV/cable and folk
artist groups
Development and
implementation of
outdoor media
such as hoardings
and wall paintings
X
X
X
X
X
X
socio/economic
exclusion
Community networks
not available
everywhere,
Maintaining the
motivational levels of
volunteers. Proper
coordination of
volunteer activities
Lack of access to
media in the case of
women
(Community)
AWWs, /
ANMs/ASHAs
AWWs ,AMNs and ASHAs
with enhanced counseling
and IPC skills and
sensitized on social
Development of
training module
and programme for
training of Master
X Trickle-down training
insufficient to
strengthen
counseling and IPC
exclusion issues to
communicate effectively
with families to promote
immunization
AWWs, ANMs and ASHAs
provide mothers with skills
to initiate immunization
through household level
visits, prior to and after the
child’s birth
trainers on
counseling and
interpersonal
communication
skills and social
exclusion
Counseling skills
and interpersonal
communication
training for front-
line health and
nutrition workers
Development and
supply of IEC/IPC
materials
X
X
X
X
X
X
skills; worker
motivational levels
low
Inadequate/
insufficient HH
contacts; social
exclusion
Inadequate
institutional reach to
urban poor families
(Community)
Village
communicator
Village communicators
equipped with
interpersonal
communication skills and
IPC training for
village
communicators on
promoting
X X X Inactive or absence
of community
groups, networks and
volunteers
s, NGO
workers, self-
help groups,
PRI/health
committee
members,
RMP’s
mobilized to promote
immunization – especially
by promoting family level
support to the mother, and
follow-up at the 2-3 month
period to sustain the
practice
Self-help groups,
Panchayats, religious
groups, effectively
mobilized to create a
positive village norm for
immunization, and also
able to ensure rural
practitioners promote
accurate information about
immunization
Communication material in
support of immunization
used by volunteers, rural
medial practitioners, SHGs
& youth groups when
immunization
Orientation for
rural medical
practitioners,
SHGs,
Panchayats/religiou
s networks who
interact directly
with families
Development and
supply of IEC/IPC
materials
Local and mass
media outreach
through radio,
X
X
X
X
X
X
X
X
Inadequate skills and
knowledge to
effectively promote
complete
immunization
Activity not
monitored and
supervised
adequately
Media reach to rural
women typically poor
and inadequate
promoting immunization
Self-help groups,
community meetings
facilitated to support AWW
in promoting immunization
in those homes where
immunization is not
practiced
Song and Drama,
DFP, cinema slides,
TV/cable and folk
artist groups
Development and
implementation of
outdoor media
such as hoardings
and wall paintings
X X X
(Institutional)
Health and
nutrition
supervisors,
managers and
professional
staff at sub-
centres, PHCs,
district
hospitals;
members of
Supervisors, managers and
senior professional staff in
Family Welfare and WCD
able to advocate within
their departments and to
district and block
administrators for continual
and intensive support for
efforts to promote
immunization
Health centres (from sub-
centres to district
Preparation and
dissemination of
advocacy materials
to senior managers
and administrators
Development and
implementation of
outdoor media
such as hoardings
and wall paintings
X
X
X
X
X
X
Difficult to ensure
quality
implementation of
outdoor media
Coordination with
professional bodies
often difficult.
local
professional
organizations
and institutes
hospitals) and AWW
centres increase visibility
around immunization
through fixed-site
information posts
Professional medical and
health associations in the
district effectively engaged
to promote immunization
through public
engagements, visibility
events and media outreach
Regular briefings,
workshops and
orientations with
health and medical
associations
X X X X
(Institutional)
Local and
mass media,
reporters,
producers,
station
directors
DD and AIR mobilized and
disseminating key
messages on immunization
through ongoing and
special programming,
Public Service
Announcements and
publicity around
immunization Week
MOU with DD and
AIR to support
increased
programming
around
immunization
Content
development,
X
X X X
Insufficient
programming time
dedicated to
immunization
Outreach, quality of
implementation
issues
Song and Drama, Dept of
Field Publicity promoting
immunization at community
level through folk
performances, video and
film shows
Print media providing
adequate and supportive
coverage
production support
for special and
ongoing
programming on
DD and AIR
MOU with S&D, FP
units and
implementation of
district level
communication
activities
Workshop with
DPROs
Development of
briefing package
for Media
Media visits/
Fellowships /
X
X
X
X
X
X
X
X
Awards