part1: operational guideline

i

2012

Immunization Division Ministry of Health and Family Welfare

Government of India

Intensification of Routine Immunization

Communication Operational and Technical Guideline

(2005-2012)

iii

AcknowledgementsThe Intensification of Routine Immunization in India: Strategic Communication Guideline has

been produced using wide consultation, and represents valuable inputs from a large number

of individuals from among staff and consultants in the Immunization Division, Ministry of

Health and Family Welfare, Government of India, and programme and communication staff

from among many Development Partners.

Credit is due to UNICEF for providing active support and coordination in the development of

this document. Efforts made by the lead author, Bhawani Shankar Tripathy, Communications

Consultant with UNICEF, in bringing this valuable document from inception to final shape are

sincerely acknowledged. The strategy was keenly reviewed by Dr Satish Gupta, Immunization

Specialist (UNICEF), Dr Renu Paruthi, Training Specialist (WHO), and Mr Mario Mosquera,

Communications for Development Specialist (UNICEF).

The leadership of Ms Anuradha Gupta, Additional Secretary, and MD, NRHM, through the

journey of the development of this document, has been inspirational and is gratefully

appreciated. Dr Ajay Khera, DC, Child Health and Immunization, provided professional

guidance that helped to give this guideline its present shape.

Critical insights during discussions was provided by a number of experts, including Dr Pradeep

Haldar, DC, Immunization (MoHFW); Dr Navneet Kumar Dhamija, DC, Immunization (MoHFW);

Dr M.K. Agarwal (MoHFW), AC, Immunization; Dr Bhupendra Tripathi (UNICEF), Dr Vijay Kiran

(MCHIP), Dr Sachin Gupta (MCHIP), Ms Rina Dey (CORE), Dr Narottam Pradhan (UNOPS), Mr

Rod Curtis (UNICEF), Ms Sonia Sarkar (UNICEF), Dr Srihari Dutta (UNICEF), Nidhi Dubey (Global

Health Strategies) and Ms Meenakshi Aggarwal (Solutions Exchange, MCH Group).

Naming everyone who contributed to this guideline will be difficult here, but their timely

advice is sincerely acknowledged and appreciated.

iv

AbbreviationsADS Auto Disable Syringe

AEFI Adverse Event Following Immunization

ANC Ante Natal Care

ANM Auxiliary Nurse Midwife

ASHA Accredited Social Health Activist

AVD Alternate Vaccine Delivery

AWC Anganwadi Center

AWW Anganwadi Worker

BCG Bacillus Calmette Guérin

BMO Block Medical Officer

CBO Community Based Organization

CHC Community Health Center

CMO Chief Medical Officer

CNA Community Needs Assessment

CS Civil Surgeon

DH District Hospital

DIO District Immunization Officer

DT Diphtheria Tetanus

DPT Diphtheria Pertussis and Tetanus

EPI Expanded Program on Immunization

FAQ Frequently Asked Questions

GoI Government of India

HW Health Worker

HepB Hepatitis B

IACC Inter-Agency Coordination Committee

ICDS Integrated Child Development Scheme

IEC Information Education and Communication

ILR Ice-Lined Refrigerator

IM Intra-Muscular

IPC Interpersonal Communication

JE Japanese Encephalitis

JSY Janani Suraksha Yojana

MO Medical Officer

MoHFW Ministry of Health and Family Welfare

NFHS National Family Health Survey

NGO Non-Governmental Organization

NIDs National Immunization Days

NIS National Immunization Schedule

NRHM National Rural Health Mission

OPV Oral Polio Vaccine

PHC Primary Health Center

RI Routine Immunization

RIMS Routine Immunization Monitoring System

SC Sub-Center

SHG Self Help Group

v

ContentsPART 1: COMMUNICATION OPERATIONAL GUIDELINE [WITH ANNEXURES]

GETTING ORGANIZED ............................................................................................................................. 2

ORGANIZE CAPACITY BUILDING OF HEALTH WORKERS .................................................................................. 15

CONDUCT ADVOCACY ACTIVITIES ............................................................................................................ 18

CONDUCT SOCIAL MOBILIZATION ............................................................................................................ 24

MONITOR AND EVALUATE..................................................................................................................... 30

PREPARE FOR MANAGING CRISIS (AEFI)................................................................................................... 32

REACH OUT TO HARD-TO-ACCESS AREAS................................................................................................... 35

COMMUNICATION FOR INTRODUCTION OF NEW VACCINES ............................................................................... 37

CAMPAIGN COMMUNICATION................................................................................................................ 39Annexure 1.1: Channels and vehicles for message delivery................................................................... 45Annexure 1.2: Immuni IEC/IPC planning format* ........................................................................ 47Annexure 1.3: Research, Monitoring and Eval on ............................................................................ 48Annexure 1.4: M&E Format .................................................................................................................... 49Annexure 1.5: How to organize a media conference ............................................................................. 50Annexure 1.6: Prototype of TNA Form.................................................................................................... 52Annexure 1.7: Key ques ons for monitoring and supervision of immuniza on sessions ..................... 53Annexure 1.8: A typical IPC role-play training session .......................................................................... 54Annexure 1.9: Campaign IEC Planning Grid ........................................................................................... 55Annexure 1.10: Prototype of an advocacy l er seeking support......................................................... 56

PART 2: TECHNICAL GUIDELINE [WITH ANNEXURES]

DEVELOPING THE COMMUNICATION STRATEGY .......................................................................................... 57

GUIDELINES FOR DEVELOPMENT AND USE OF EXISTING IEC PROTOTYPES .......................................................... 65

GUIDELINES TO DEVELOP PRINT MATERIAL FOR AUDIENCES WITH LOW LITERACY LEVELS ...................................... 69Annexure 2.1: Communica on Strategy SmartChart............................................................................. 73Annexure 2.2: Desired behaviours .......................................................................................................... 75Annexure 2.3: Key behavioural barriers ................................................................................................. 75Annexure 2.4: Quan ve data on caregivers’ behaviours and pr es regarding immuniza .. 76Annexure 2.5: Qua ve inform behaviours........................................................................... 76Annexure 2.6: Factors associated with non-immuni n.................................................................... 78Annexure 2.7: Reasons for dropouts and le outs.................................................................................. 79Annexure 2.8: Reasons for low immuniza on in urban areas....................................................................80Annexure 2.9: Behave Framework.......................................................................................................... 81Annexure 2.10: Cre e Brief Format .................................................................................................... 82Annexure 2.11: Checklist for produc on of material for audiences with low literacy levels ................ 83

REFERENCES ...................................................................................................................................... 85

vii

IntroductionYear 2012 has been declared by the Government of India to be the “Year of Intensification of Routine Immunization,” and BCC gains critical importance in raising immunization coverage in the country. Especially when India is poised to introduce new vaccines, behaviour change towards creating demand for immunization with tried-and tested traditional vaccines in all the more important. There is a need to rethink, strategize, and position RI appropriately.

The objective of this document is to share guidelines, strategic approaches, and tools with immunization officers in the field so that local-level BCC plans can be developed and implemented effectively. Participation from a wide range of stakeholders is anticipated and recommended.

Ideas for developing this guideline have been drawn from various sources – field experiences, books, reports, KAP studies, web articles, published and unpublished papers, seminar presentations, and discussions, and documented individual experiences. All sources are gratefully acknowledged, with the important ones listed under “References” at the end of this guide.

Users of this guidelineThe guide is meant primarily for immunization programme managers and IEC functionaries at the state, district, and block. A potential list of users of this operational guide is given below. (Designations may vary from state to state, and at-par staff may not be available equally in all states).

1. State/District Immunization Officers 2. Immunization Program Managers 3. State IEC Officers 4. State/District IEC Consultants 5. District Mass Media Officer 6. Chief Medical Officers 7. District Education Officer 8. Health workers supporting implementation (eg, ANM, AWW, ASHA, Male Health

Worker) 9. Development partners 10. Local non-governmental organizations 11. Communication agencies

viii

There is a whole range of individuals, institutions, networks outside the government system too who can will find this guide useful and participate in different ways in the IEC/BCC initiatives. Only by developing shared objectives, increased coverage goals can be achieved.

Process to use this guideline The strategic guideline provides a proposed roadmap for effectively developing and implementing strategic communication activities in immunization. It is not a strategy in itself, because that will be beyond the scope of this document. Neither can one communication strategy be ever applicable to all places and at all times. Social, political, demographic, and cultural characteristics are distinct to each state and place, and will keenly influence the method of communication used. The best way to use this guide, therefore, is as a reference document. By following the methodology and processes proposed and drawing ideas from the document, state immunization programme officers and IEC/BCC officers must be able to implement jointlycustomized communication strategies. Innovation in implementation is encouraged.

Structure of this guideline This Operational Guideline has been divided into two parts, each part in a different colour-coded bar for easy reference. Each part has its independent Annexure.

PART 1: Operational Guideline: Putting a Communication Strategy into Actionprovides step by step guidelines on the process that needs to be adopted to plan and carry out effectively a communication strategy in immunization. Any operational plan has three phases: 1) Planning; 2) Implementation; and 3) Evaluation. The guide begins with preparedness and situation analysis and ends with monitoring and evaluation. Wherever possible, best practices received from various sources have been used in boxes as successful examples of strategies that have worked.

Section 2: Technical Guideline: Developing a communication Strategy provides step by step guideline on developing a behaviour change communication strategy. A Strategic Framework (Strategy SmartChart) guides the development of the strategy. While it is common knowledge that development of an effective communication strategy must precede operationalizing the strategy, it must also be remembered that much planning needs to be done before a communication strategy can be developed. A behaviour change communication strategy with the objective to create demand for immunization and to reduce drop-outs and left-outs can only be developed by a communication specialist with adequate knowledge and experience of behaviour change communication. Hence a different section is devoted to it.

Annexures: Both PARTS have their independent Annexures that contain variousreference information and formats for use during development and implementation of communication activities. These will be referred to by the strategy developer and by the Operations team as and when advised throughout the document.

1

PART1: OPERATIONAL GUIDELINE

mmunization coverage in India ranges between 88% in Goa and 25% in Arunachal Pradesh (See chart below from Coverage Evaluation Survey 2009). There are a number of different factors that can be attributed to why Goa has such high coverage and

Arunachal Pradesh such low, beginning with different demographic and geographical factors to those related to service delivery and community demand. Even within the same state, different districts show different immunization coverage rates. In such scenarios, there will be a need for customized communication strategies according to the existing barriers. For instance, while in Goa the communication strategy will be focused on sustaining the existing high coverage rates, in Arunachal Pradesh it will be on increasing demand for immunization.

Operationally, for State Immunization Officers (SIOs) this means that communication strategies are the starting point of an effective operational plan. Broadly, this means that a successful communication action plan will be one that is based on local evidence, is strategic, has the necessary resources to implement it, focused on results, and is monitored well. [See Section 2 for the process of designing a communication strategy and guidelines for development of communication tools, which should be based on evidence from your state.]However, it also means that SIOs will need to take action that can ensure effective development of communication strategies and their implementation. These actions will be the broad operational processes, planning about what needs to be achieved; who will achieve it; how this will be achieved; by when; how much will be required; how will it be measured; and what to do in case there is an unfortunate crisis.

The following pages provide step-by-step guidelines for SIOs to manage any communication plan in immunization.

I

5

0%10%20%30%40%50%60%70%80%90%

100%

And

hra

Prad

esh

Aru

nach

al P

rade

shA

ssam

Biha

rCh

attis

garh

Del

hiG

oaG

ujar

atH

arya

naH

imac

hal P

rade

shJa

mm

u &

Kas

hmir

Jhar

khan

dKa

rnat

aka

Kera

laM

adhy

a Pr

ades

hM

ahar

asht

raM

anip

urM

egha

laya

Miz

oram

Nag

alan

dO

riss

aPu

njab

Raja

stha

nSi

kkim

Tam

il N

adu

Trip

ura

Utt

ar P

rade

shU

ttra

khan

dW

est B

enga

lU

Ts c

ombi

ned

IND

IA

Immunization Status Among 12-23 month Children by States

Full Immunization Partial immunization No Immunization

2


Getting organizedImmunization Communication Coordination Group and District Communication Coordination Group Form an Immunization Communication Coordination Group (ICCG) at the state level. ICCG must be inter-sectoral. Involve at least one representative from other government departments, IEC, Department of Audio Visual Field Publicity, leading NGOs, frontline workers, development partners, and key representatives from media, and communication professionals – representatives from advertising, radio and TV. Ensure presence of one full-time communication professional. Make sure all members of this team understand the objectives of the ICCG and their role in it. Proposed members must include:

1. State Immunization Programme Manager (SEPIO) 2. State Programme Manager (NRHM) 3. Information and Education Officer (Health Dept) 4. State Cold-chain officer 5. Officer from the Department of Audio Visual Field Publicity 6. Two or three key District Immunization Officers (DIOs) 7. Surveillance Medical Officer (WHO NPSP) 8. State RI officers/consultants (UNICEF) 9. Two District Programme Manager (NRHM) 10. Two Cold Chain Technicians 11. Two District Health Information Officers 12. Mass Information and Education Officer (Health Dept) 13. Deputy Mass Information and Education Officer

Proposed members on the District Communication Coordination Group (DCCG) are: 1. The District Collector 2. The District Immunization Officer 3. Surveillance Medical Officer (WHO NPSP) 4. Divisional/District Health Consultant and SMNet staff (UNICEF) 5. District Programme Manager (NRHM) 6. Cold Chain Technician 7. District Health Information Officer 8. Deputy Mass Information and Education Officer 9. Block Educator

3


10. Member of the local Municipal Corporation 11. Member of the Village Health and Sanitation Committee

Facilitate appropriate basic training for ICCG and DCCG members to increase their understanding of development and implementation of communication strategies. The person/agency facilitating the workshop should be BCC professionals.

NOTE: Remember to involve the State IEC Bureau, including the IEC staff within the Health Department, at the outset for all the communication activities.

Recommended Tasks for the ICCG

1. Play the facilitating and supporting role for effective development and implementation of the Immunization communication strategy

2. Map human resources available for communication – number of people at the state, districts; additional staff needed; staff from other departments such as from State IEC Bureaus, Education, Child Welfare, Municipalities in urban areas; development partners; and non-government and local community-based organizations, self-help groups

3. Develop reporting structures at different levels. Create focal points, develop reporting processes, assign responsibilities, and ensure accountability

4. Facilitate state-level knowledge-attitude-practice (KAP) research if not available 5. Participate in conducting the situation analysis vis-a-vis state/district coverage 6. Mobilize and allot financial resources from within state and nationally 7. Conduct advocacy for inter-sectoral support, partnerships and collaborations at state 8. Facilitate the development of the state and district communication plans 9. Develop and implement capacity-building activities for ICCG and DCCG members 10. Provide support for capacity building of frontline workers at the district 11. Oversee implementation of the communication activities at the state and district level 12. Strengthen media relations at the state level through appropriate media advocacy 13. Conduct state-level mass-media activities supporting communication strategy 14. Develop and brand immunization; provide branding and communication tools to DCCG 15. Support financially for monitoring, evaluation, documentation and utilization of data

collected from the district 16. Make policy decisions for offering incentives for specific communication activities 17. Oversee the Adverse Events Following Immunization (AEFI) Committee 18. Update the Immunization Focal Person at the Ministry of Health and Family Welfare,

Government of India, about progress in communication and seek support if needed

4


Recommended Tasks for the DCCG

1. Map human resources available in the district for developing and implementing the communication plan

2. Identify reporting structures at different levels in district. Create focal points, develop reporting processes, assign responsibilities, and ensure accountability

3. Conduct situation analysis vis-a-vis district coverage 4. Develop the District Communication Action Plan (DAP) 5. Advocate to mobilize resources from state and from within district 6. Develop and implement capacity-building activities at district level 7. Develop district-specific communication tools if necessary 8. Implement communication activities as per the DAP 9. Monitor, evaluate, document communication activities 10. Hold regular meetings to analyze progress and do mid-correction 11. Promote inter-sectoral partnerships and collaborations at the district level 12. Establish media relations at district 13. Oversee the District AEFI Committee 14. Update the ICCG Focal Person at the state about progress in communication

Meetings of ICCG and DCCG and Record of Discussion Initially, the ICCG must meet once every fortnight till the development of communication strategy, moving to monthly meetings. Initially, the DCCG must meet once every week till the development of communication strategy, moving to fortnightly meetings. For preparatory meetings, have powerpoint presentations to discuss the following:

o The process of developing the communication plan o Individual responsibilities and team responsibilities o A plan to review progress of tasks o Timelines for submission of individual and team tasks o Implementation plans o Monitoring and evaluation plans o Documentation and dissemination

Remember to maintain a ROD (Record of Discussion) – always! Disseminate the ROD to all stakeholders to strengthen internal communication

NOTE: Focus on thorough planning on the low performing-districts. When they perform well, they should help improve the overall coverage for the state.

5


Gather data and evidence A key role of the ICCG will be to ensure adequate qualitative and quantitative data is available from the districts, which will be necessary to develop an effective communication strategy and communication micro-plan, including the situation analysis. A Situation Analysis also helps to identify the baseline against which progress of communication activities can be measured later.

NOTE: See Annexures 2.4-2.6 for national data from different surveys. Evidence-based district data must be provided to the people developing the communication strategy.

If quantitative/qualitative data is not available

Facilitate formative research and use of research findings Take actions to get surveys conducted. Identify agency and financing. Prepare survey questionnaires, or seek from other states, or partner agencies. It is ideal for each district to have its separate data. This will help identify district-specific communication action plans (DAPs). Consolidate district data for common messaging to be promoted at the state level.

Develop communication microplans A communication microplan will borrow many elements from the programme microplan. It must have answers to some of the most important factors that influence effective communication. While planning, begin with the smallest unit in the district – the village – and work up to town and city. Get as much information as possible on:

Demography o Percentage of targeted stakeholders with literacy level o Dominant social and cultural norms o Major occupations o Level of migration o Health seeking behaviours (traditional practitioners?) o Presence of immunization messages

Geographical o Location and accessibility o Any central locations where people collect periodically, such as temples,

maidans, bus depots, etc Health System and infrastructure

6


o ASHAs, AWWs available or not? o PHC/sub-centre availability

Media behaviour o Most popular communication process used (information flow process) o Sources of information: mass media/personal/community communication o Availability/Possibility of using certain communication channels

Session and Outreach vaccination sites o Number of session sites o Number of outreach booths

Enabling infrastructure for IEC/IPC o Locations for training o Public sites for IEC material display

Develop the strategy Guidelines for developing a communication strategy are given in PART 2 of this document named “Techincal Guideline.” The development of the communication strategy must be done by a team of communication professionals/agency with support from the ICCG members. Districts will prepare District Communication Action Plans (DAPs) based on the same strategic framework (the Strategy SmartChart) as given in PART 2. Consolidate the DAPs to arrive at budget and resource needs for operationalizing the strategy.

Prepare a gantt chart of activities Based on the microplan and the strategy developed, prepare a time line chart, beginning with the first meeting of the ICCG to development and approval of strategy to monitoring, evaluation and documentation.

A one year plan must be put in place. Always work backwards month-wise or week-wise keeping March 2013 as the last month of operation

An example of a simple gantt-chart for the major steps in the Operational Plan is given below for the remaining nine months in the financial year 2012-13. A more detailed gantt-chart will list out the various activities under each of the five given stages of the Operation Plan. For easy visual reference, each phase of activities will be indicated in separate colours. A separate chart can be created for each phase of the plan.

7


SNo Activities and time assigned

July 2012

Aug 2012

Sept 2012

Oct 2012

Nov 2012

Dec 2012

Jan 2013

Feb 2013

Mar 2013

1 Planning

2 Implementation

3 Monitoring

4 Evaluation

5 Documentation

Remarks

Prepare fund allocation and utilization plan for operationalizing communication activities Three aspects need attention here: 1) Budget heads; 2) Total costs; 3) Source of funds. Standard budget heads will be for the following broad activities. (An example of an operational budget chart is given on the next page).

1. Research (gathering and compiling relevant district data if not available) 2. Development and printing of IEC materials 3. Distribution costs of IEC material 4. Development of mass media material 5. Broadcasting costs of mass media 6. Training costs 7. Workshop costs 8. Transport 9. Equipment hiring/purchase 10. M&E costs 11. Documentation costs

Source of Funds

Besides the regular funding source from Health/Immunization, it is important to know who else is working on immunization. These partners can contribute resources (if not in cash) by taking charge of a particular activity, such as sponsoring workshops or training programmes

Seek different resources from within the system (such as NRHM funding)

8


Piggyback on communication plans of partner departments/ministries, IEC Bureau Seek funding support from development partners, NGOs

Broad operational heads for which costing will be required: Budget Heads Costs Source of funds Personnel Salaries+benefits+incentives Consultant fees Meetings for planning Data collection (if any)Training for data collection Travel allowances for field work Data analysis, report preparation Special events Giveaways, stickers and T-shirts Conferences and launches Honoraria for dignitaries and celebrities Others Capacity Building Curriculum development Consultant and trainer fees Per Diem and accommodation for participants Hiring of training sites, equipment purchase of rental Production of broadcast material Fees for creative agency Pretesting Airtime Production of IEC material Fees for comm agency Pretesting of material Printing and distributionConduct of mid-media activities Hiring mid-media agency Supervision costs Monitoring and evaluation Hiring M&E agency, fees Training of surveyors Travel and accommodation Secretariat costs (if any) Communication–telephone, internet, fax, posting Supplies Report writing

9


Brand immunization Promote the key message “Ashirwad swasth zindagi ka”

Ensure that during all opportunities – visual or spoken – immunization continues to be branded. Currently, immunization is being branded as:

“Ashirwad swasth zindagi ka”

You will notice all IEC material on Routine Immunization developed by the Immunization Division at the Ministry of Health in 2011 carry the following key line:

“Sahi Samay Sahi tika, ashirwaad swasth zindagi ka” (in Hindi)

“The right vaccine at the right time; blessings for a health life.” (English)

The brand line is accompanied by the visual of a large caricature of a happy syringe holding a happy baby in its arms. The development of this brand image was pretested in the communities in Bihar and found acceptable. The brand was used proactively and successfully in the immunization campaign called “Muskaan”of the Government of Bihar. With permission from UNICEF, Bihar, which developed the visual, it is now being widely used in all IEC material under UIP.

It has to be remembered that barring polio drops, all other vaccines in the RI schedule are injectable. The image conveys this clearly. It also personifies the syringe and needle as a parent holding a baby in its arms, which is very happy and

comfortable conveying the fact that injectable immunization is safe for the baby.

NOTE: Monitor branding exercise.

Visual Branding Use visual branding at all possible immunization locations: Outreach sessions, sub-centres, anganwadi centres, PHCs, CHCs, District Hospital. Use the brand image on banners, kiosks, translides, tin plates, wall paintings, vaccination vans, IEC material and mass media material, and on other formats depending on resources and location possibilities.

10


Facilitate pretesting of key messages

Messages are what your key stakeholders are going to hear from you and understand from the communication that you use. Your objective behind the messages is to make your stakeholders take a certain action, whether it is with the decision maker or with the community or the single parent. Note the following:

1. The ICCG/DCCG members responsible for overseeing development of communication strategy must oversee development of targeted messages.

2. The people/agency developing the strategy must develop the messages. 3. Gather evidence on the kind of messages that have been previously communicated to

the stakeholders, and the channels and vehicles used to deliver the messages. Repeating the same messages in the same manner will be a waste of time and money.

4. Check appropriateness of messages – culturally sensitive, easy to understand, direct, local and within the intellectual capacity of the stakeholders to understand

5. Ensure messages have an “ask”. 6. Get messages pre-tested before communicating them to stakeholders. Hire a third-party

agency to do pretesting (not the same people/agency that developed the messages). 7. Pass a budget for pretesting. Budget will involve training of pretesting staff, travel board

and lodging , focused group discussions (FGDs) and indepth-interviews, cost for hiring presentation equipment necessary for FGDs such as VCD players, TV, audio-recorder, may be a battery (for non-electrified locations), laptops, and documentation.

8. Change messages midway if they are not working.

Identify channels and vehicles for delivering messages Select channels on the basis of the communication objectives. Vehicles are mediums within each channel. Channels are of three types as given below. 1. Mass media can be cost effective in sending information quickly to a broad audience;

(limitations: awareness creation). Not for complicated messages. 2. Interpersonal communication (IPC; e.g., physicians, friends, family) are influential

context for health messages. 3. Mid-media – Group channels (e.g., schools, SHGs) can reinforce messages and offer

instruction. Easier to establish communication links more quickly than developing individual IPC channels.

NOTE: Prepare a budget once a specific channel is approved. For a list of channels and vehicles, and their effectiveness for communication, see Annexure 1.1.

11


Events (mid-media) can be effective for community mobilization

Arunachal Pradesh “Healthy Baby” competition Chandigarh: Street play in school

Gujarat: Save the girl child road show Gujarat: Beti Vadhao Yatra-Surat to Somnath

Tripura: Mass community mobilization Tripura: Stage theatre for community mobilization

LESSON: Nalamdana (Are you well ), Tamil Nadu A theatre group that believes entertainment can be used to communicate information about socio-emotive sensitive issues. Nalmadana’s mission is to provide health education and promote preventive behaviours through entertainment methods. Ordinary people from the community participate in these programmes organized from village to village. A second objective is development of local leaders who can harness the cooperation of the critical mass needed for change.

12


Develop IEC and IPC tools Communication tools (IEC material, including IPC products such as Flipcharts) must be dictated by the strategy and the channel of communication, not by assumptions. DCCG must calculate the volume of IEC and IPC products that will be required based on the microplan, that is number of sites where IEC material can be put up. These sites are of two types: 1. Immunization booths 2. Public places (bus terminals, market places, bus panels, etc)

First identify what communication tools already exist in the state/district. The ICCG/DCCG must have a list available with them; make inventory of what is available, where, how many, and whether in digital format or printed format Conduct a SWOT analysis of the usability and quality of available material Identify agency/people who will develop further communication tools if required Provide creative briefs to agency developing communication tools ICCG must develop mass-media communication products such as TV and radio spots. ICCG must do bulk printing of IEC and IPC tools that will be common to all districts. The ICCG will only develop the amount of material that the DCCG requisitions for The DCCG must develop and produce district-specific material and tools if necessary but only after approval on content and messaging from the ICCG

Ensure creative briefs are written

A creative brief is written to enable the creative team to produce communication material.

1. What is the objective of producing the communication material? 2. Who is the targeted audience for the communication material, and what action is

expected from that audience? 3. What are the social/psychological characteristics of audience, and media habits. 4. How will the material be pretested for effectiveness and implemented? 5. How will the impact of communication material monitored and measured? An example of a Creative Brief chart is at Annexure 2.10. It is not mandatory to use the format as given. Simply ensure the brief mentions the necessary elements

NOTE: Based on the DAP microplan, districts will provide the total numbers of each IEC products required. Use the chart available at Annexure 1.2.

13


Adapt IEC and IPC prototypes already available IEC material on immunization has been developed by MoHFW. These prototypes have been distributed to all states.

1. IEC prototypes comprising posters, hoardings, newspaper advertisements are available to be used to promote the following vaccinations.

1. Routine immunization 2. Birth Dose 3. Measles 2nd dose 4. JE 5. Pentavalent

2. Guidelines for development and use of IEC material

Other IEC communication tools 1. Frequently Asked Questions (FAQs) on RI, Measles, Pentavalent 2. IPC Training Film on Immunization called “Tikakaran par kuch saral baatein” adapted

from the Entertainment-Education TV serial called Kyunki3. RI training film for health workers (20 min) by ImmunizationBasics 4. TV spots and radio jingles featuring celebrities Sahrukh Khan, Juhi Chawla , Mona Singh 5. Advocacy film on measles campaign from Gujarat 6. Advocacy film on immunization during a VHND in Gujarat 7. Film on how to conduct VHNDs (JICA) 8. ASHA Newsletter (MoHFW) 9. Catch-up Newsletter (MoHFW)

NOTE: Guidelines for development and use of existing IEC prototypes are provided in Section 2 of this document. At the state level, different states will also have a number of IEC material. Opportunities and networking must be used to share IEC/IPC material and implemented after their appropriateness have been approved and pre-tested.

Distribute IEC products All IEC material must be distributed to the districts through the DCCG. The DCCG will further distribute material to blocks as per microplan, and ensure that the material reach the designated officials and are used as per the recommendations. The DCCG must monitor and document the use of material and provide a report to the ICCG periodically.

14


Recommended locations to display posters and hoardings

To be displayed at places which provide high visibility from a long distance.

Imp Note:These are indicative locations.

You may identify additional strategic locations in different areas of your district/village.

Please seek permission from local municipalities/owners of premises/other local authorities before displaying any poster/hoarding.

Please advise your vendor/poster-pasting-agency strictly not to paste posters on any signage put up by the local municipality that may cause inconvenience to the public.

Public Places 1. District hospital /Pvt hospitals 2. CHCs, PHCs, Sub-centres, Anganwadi centre (ICDS) 3. Bus stands (and inside waiting room) 4. Railway stations (and waiting room) 5. Market/mandi area 6. Cinema theatres 7. Panchayat bhawan (Inside Panchayat bhawan) 8. Village choupal9. Entry and exit points of villages 10. District Collector’s office

Additional sites for posters 1. Medical Institutions / other institutions 2. VHND sites 3. School notice boards (small posters 19” x 29”) 4. Ration shops (PDS stores)

(small posters19 x 29”) 5. Chemist shops (smaller posters 19 x 29 inches) 6. Tea stalls (smaller posters 19 x 29 inches) 7. Any other place where people gather in large numbers

At District Hospitals, CHCs, PHCs 1. Convert into back-lit Translides 2. Wall paintings 3. Run videos on LCD screens 4. Distribute as leaflets or handouts (also during miking)

Cost of producing postersof the following specification: Size: 19x29”

Colour: 4 colour throughout

Paper: 90GSM Indian Chromo Art

Quantity:100,000

Approx Cost: Rs 4 per poster

Cost of producing bannerof the following specification: Cloth rally banners

Material: Soft sheeting fabric without sta100% cotton

Ready size: 17”x72” exclusive of a 3” bordeach side to be stitched on 17” side

Fabric weight: 110 gms per sqm

Color: Fastness to water

Tensile strength: 120 N, Tear strength: 6N

Printing: 2 col printing single side

Text and visuals as per design

Amount: 10,000 banners

Approx Cost: Rs 30 per piece

Cost of producing posters of the following specification: Size: 19x29”

Colour: 4 colour throughout


Quantity:100,000


Cost of producing banners of the following specification: Cloth rally banners

Material: Soft sheeting fabric without starch, 100% cotton

Ready size: 17”x72” exclusive of a 3” border each side to be stitched on 17” side








15


Organize capacity building of health workersMany of the behaviours of caregivers are directly influenced by behaviours and attitudes demonstrated by health workers (See Annexure 2.7). Training of health workers in IPC skills therefore becomes mandatory to create demand and reduce drop-outs and left-outs.

Begin with a Training Needs Assessment (TNA)

The TNA process begins with preparation of assessment questionnaires and identification of participants. Assessment questionnaires will be prepared for two levels:

1. Frontline health workers – to gauge skills possessed for IPC 2. Community – to gauge expectations from service providers

The TNA will broadly focus on assessing the following four skills:

1. General communication skills 2. Counselling skills 3. Inter-personal communication (IPC) skills for delivery of key messages on RI 4. Skills in group communication and during home visits

See Annexure 1.6 for a sample of a questionnaire for TNA.

Prepare a training plan Based on the TNA report, prepare training plans for the districts. This will outline:

Suggested training dates Sessions (for a sample session format, see Annexure 1.8)Participant profile and numbers Venue (must be large and well-equipped to conduct interactive group activities) Travel days and related logistics such as budget and other resources

The district training plan will be prepared in conjunction with CMO, DIOs and DPOs from H&FW and partners. Training batches will be divided as per the levels required.

Identify Trainers The team of District Trainers will be identified from the districts. Explore with partners and previous training programmes for trainers. The selection process will include Group Discussions followed by interviews by Lead Trainers.

Identify Supervisors Lead Trainers within the districts or from among partner agencies along with selected members from ICCG and DCCG will perform as monitors and supportive supervisors.

16


Conduct Training of Trainers A Training of Trainers (TOT) will be organized for these District Trainers. Submit a training report on completion of training. For the TOT, a checklist will be used by the Lead Trainers for the grading of the District Trainers. Grading will be conducted based on (i) skills in facilitation, communication, motivation, and presentation, and (ii) knowledge.

Develop Training Kit for health worker training

Preparation of Training Modules and Tools based on the TNA Training tools include:

Facilitator guide (modules based on job profiles, roles and responsibilities of groups) Participant manual at each level of participants (ASHA, AWW, ANM, Supervisor, LHV, Male supervisor) based on the roles and responsibilities IPC tools identified from existing materials available in the state (flip book, flash card, games, comic strips, videos, etc) User guides for communication materials Quality assurance checklist for TOT, training and post-training

Suggested training tools

Simple job aids: Every health worker should have a simple job aid with immunization messages: when to return next; what to do on side effects, how many vaccinations remain and how to congratulate the parent. Develop and print these job aids by engaging professional communication agencies. IPC skills training video (based on TV programme Kyunki by UNICEF). Facts for Life videos (by UNICEF) on immunization. Supervisor Checklists. These checklists should include questions about whether the parent is counseled and on what key messages. Supervision should also cover professional behavior. Does the health worker congratulate parents, makes them comfortable, or criticize them? Feedback form to enable the participants to provide feedback following which training curriculum and methodology can be improved.

Implement the training programme

A good idea is to conduct initial demonstration trainings (2 or 3 is enough) to measure the strengths and gaps in the training. Lead Trainers will analyse these demonstration trainings, prepare reports and carry out remedial activities. Conduct trainings as per training calendar. For a sample session format, see Annexure 1.8.

17


Assess the training programme

A standardized monitoring format (with qualitative and quantitative parameters) will be prepared for District Trainers. Forms will be filled in immediately post training sessions and submitted to ICCG. Any corrections to be made in the training will be informed to the trainers immediately for application. Pre- and post- training evaluation will be conducted.

Training follow-up

Following the training, a plan should be drawn to field support and monitor the trained health workers’ actual post-training performance at field level. Ensure that the monitoring and supervision checklists are in sync. Training follow-up report will be submitted by the monitoring agency for each district separately.

Some possible challenges

Availability at the local level of IEC managers skilled in conceptualizing, strategizing and delivering integrated strategies Along with health workers, IPC training must be organized for para-medical staff too. Prepare a separate training/orientation plan Identifying local talents and experiences Working out supportive institutional plans Ensuring availability of adequate budget Monitoring and evaluation of training programmes Documentation

How to overcome the challenges

Develop a network of stakeholders at the local level – medical institutions, privately practicing doctors, civil society organizations, individual volunteers – and engage with them on a regular basis through meetings, workshops, distribution of communication material, events. Engage and seek support from development partners (international and local), NGOs, CBOs. International development organizations support the government in many different ways. They can facilitate in building capacities and sharing lessons/processes that have worked elsewhere. Seek support from private sector for resources. The private sector offers many opportunities for collaboration beyond money. They have skilled manpower and resources that can be extremely useful in times of need.

18


Conduct advocacy activitiesAdvocacy needs to be done with a range of stakeholders

Many individuals and groups – from decision makers in the government to leaders and groups within communities – can support the cause of immunization. But who to advocate with, why and when will depend on the communication strategy. Given below is a list of targeted groups. ICCG will do advocacy with state-level groups, and DCCG with the district groups. Advocacy with these groups is important for promoting immunization.

1. Policy-makers (Parliamentarians) and bureaucrats 2. Other ministries and departments besides Health 3. Media 4. Medical institutions and members networks (such as the IAP–Indian Academy of

Paediatricians and IMA–Indian Medical Association) 5. NGOs/CBOs 6. Private health practitioners (practising doctors) 7. Village-level health practitioners 8. Chemists 9. Schools 10. Other health related organizations

Irrespective of the advocacy group, ICCG and DCCG must follow the process given below:

1. Gather evidence about immunization status in state/district 2. Create easily understood charts and graphs from data available 3. Analyse existing policies and decisions among the identified advocacy group 4. Prepare a plan comprising 1) advocacy objectives; 2) positioning of message;

3) development of advocacy tools and activities; and 4) identifying outcome indicators 5. Assess available resources 6. Develop a timeline for various advocacy activities 7. Develop compelling messages 8. Develop advocacy material accordingly 9. Create networks/partners such as youth groups, religious/community leaders 10. Conduct the advocacy, and document the proceedings.

NOTE 1: Advocacy and social mobilization must be conducted simultaneously.NOTE 2: From the start, involve the IEC unit/State IEC Bureau in the development and operationalization of the communication strategy.

19


One example of an advocacy plan is given below. ICCG must identify person(s) responsible for this task.

Advocacy with Policy-makers and parliamentarians Advocacy with and among leaders in this group helps foster the commitment that will clear the way for action. The objective here is to gain consensus including the allocation of adequate resources through sound data and by creating a knowledgeable and supportive environment for decision-making. Policy-makers depend on bureaucrats, technocrats, and service professionals to provide the rationale for decisions as well as to plan and implement programmes.

Objective Positioning Priority Activities Outcome Indicators

Objective 1:High-level officials in the Department of Health are able to value immunization as extremely important for saving children’s lives, and support strengthening of the immunization delivery system with the necessary resources (financial and HR).

Objective 2: Policy-makers/High-level officials ensure high-level visibility as champions of immunization, with other policy-makers, and decision-makers.

Objective 3:Policy-makers and high-level health officials strengthen collaboration with other related departments through visible advocacy.

“Your decision can save lives of millions of children threatened by vaccine preventable diseases, and help meet the state/district/ constituency development goal (specify the goal) for which urgent and priority action is necessary.”

(The positioning of this message should be done in allcommunication material.)

Compile state/district IMR/NMR indicators (immunization related) in Factsheets, on a PPT, and a booklet.

Develop a small but attractive booklet on vaccine preventable diseases.

Make a 10-minute PPT presentation on the kind of support needed, justifying how it will help the programme. This information can also be put as a four-pager.

Develop a small handout highlighting “initiatives-taken, what all is planned and what needs to be done.”

Sensitize at face-to-face meetings.

Invite for presentations and workshops.

Invite to launch events, during immunization campaigns.

Facilitate advocacy meetings with other departments such as Education, Women and Child Development, Water and Sanitation, and Municipalities.

% of districts with resources allocated for strengthening of state/district immunization cold chain

% of districts fully implementing commitments made

% of events attended by policy-makers/Health Secretary

# of new partners national/international mobilized to support RI efforts

% of district immunization meetings chaired/ attended

20


LESSON: Importance of advocacy for health service improvement “It is also quite common in communities with relatively high coverage rates for mothers to arrive at the fixed-day, fixed-site immunization sessions without being informed or reminded. Field observations indicate that a high level of community participation is a logical outcome of regular and reliable services, not the other way around. Visibly regular and predictable services are more effective in obtaining “community participation” than intensified behavior change communication in the face of poor services.” (“Women and child health at scale: widening the scope of immunization.” Rachna Program; Care)

Advocacy with Media

Position immunization as “the most misunderstood life-saving health intervention which needs their support in bringing its benefits to light.”

Activities 1. Prepare list of state and district media staff covering health issues, with the latest

contact numbers, emails and official address 2. Prepare a list of Editors of major newspapers and TV channels, radio 3. Prepare district-wise list of local cable operators 4. Identify spokespersons at state and district levels. These can be the SIO/CMO/DC. 5. Ensure the spokespersons have the requisite media skills. Organize media skills training

for spokespersons if necessary 6. Prepare key message sheets on immunization and share with spokespersons 7. Prepare a list of key immunization experts at state and district level, with their contacts

and mailing address as per the hierarchy 8. Share this list with key immunization staff 9. Keep media informed periodically about progress on immunization by sharing data,

progress on campaigns, events, key decisions made, policy discussions 10. Prepare a standard press release format, use immunization logo along with state logo on

the letterhead for effective branding 11. Hold media collaboration workshops; include state-level journalists. 12. Seek the help of development partners/media and communication agencies to build

capacity of media. 13. Produce and update standard media kit on vaccine preventable diseases and FAQ on RI. 14. Provide data on immunization-related disease burden of state/district/block. Also

provide national and global data. 15. Keep them regularly informed of all immunization related developments through faxes

and emails.

21


16. Prepare and provide list of media spokespersons within the system related to immunization programme.

17. Build two strategic partnerships with national broadcast and print associations 18. Host two editor meetings. 19. Conduct media monitoring. Prepare quarterly reports on national and high-risk state

media coverage. Analyse top 10 national print media news and features for: o Number of articles on routine immunization. o Tone of article (positive, neutral, negative) o Factual vs non-factual details.

NOTE: For guidelines on conducting media conferences, see Annexure 1.5

Advocacy with other government departments such as Education, Women and Child Development, Panchayati Raj Institutions

Position “Immunization success is dependent on partnership, and directly contributes also to the goals of your departments besides health.”

Activities Develop a small but attractive booklet on vaccine preventable diseases. Make a 10-minute PPT presentation on the linkages between immunization, education, nutrition, and sanitation, justifying the kind of support needed and how it will help the programmes. This information can also be put as a four-pager handout. Provide booklet highlighting “initiatives-taken in immunization, what all is planned.” Sensitize with face-to-face meetings. Invite for presentations and workshops, especially when cross-sectoral linkages are being discussed. Invite to launch events, during immunization campaigns. Facilitate advocacy meetings between Health and other departments. Acknowledge the support received in publications, public forums, internet, media, etc.

Advocacy with medical institutions/associations/health practitioners

Position immunization as “the most cost-effective child-survival strategy in which the medical fraternity can help promote and sustain, and thus gain personal and institutional credits.”

22


Activities Keep IAP/IMA informed about initiatives in immunization programmes through correspondence. Prepare proposal and PPTs on how IAP/IMA members can support the immunization programme. Share it with local IAP/IMA chapters Support IAP/IMA members in conducting studies and research, and to advice on improving RI programme implementation. Identify and prepare a list of IAP/IMA members in the district and create networks. Invite IAP/IMA members for workshops and share M&C card and other logistics issues. Offer IAP/IMA members incentives for providing support, such as recognition certificates and awards. Induct selected senior IAP/IMA members to district immunization advisory committees. For selected senior IAP/IMA members from district, create opportunities for interviews with media, talk shows on TV and radio/FM channels. Develop mass media/IEC promotional material showcasing participation from private health practitioners. Offer opportunities to IAP/IMA members for Supportive Supervision. Seek support from IAP/IMA members during unfortunate AEFI. Seek IAP/IMA members from district for capacity building of health workers. Prepare short proposal as an aid to understand their role in supportive supervision. Prepare both print and power point presentations. Indicate how medical students can gain experience.

Advocacy with traditional healers and chemists

Position immunization as “a safe and free intervention that builds defence against life-threatening diseases in children, eradicated diseases like small-pox (with polio on the verge of eradication) from India, and saved lives of millions of children and adults globally.”

Activities Make pictorial presentations through booklets on the disease risk and benefits of immunization. Provide examples of how vaccination has helped eradicate a disease like small pox. Invite to group meetings and seek their counsel on health issues. Provide chemists with IEC materials for display in shops. Engage and offer short incentives such as certificates of recognition.

23


Carry pictures of chemist shops displaying immunization posters in the district newsletter on immunization (or contribute articles to the ASHA newsletter produced by MOHFW and distributed countrywide). Conduct capacity building programmes for traditional healers and chemists in IPC. Use existing IPC film “Tikakaran par kuch saral baatein.”

LESSON: Involving and building capacity of traditional healers (Chhattisgarh) The Chhattisgarh government used Sirha-Gunia-Baigas(traditional healers) as agents of behaviour change and to help medical service providers in their work. The Sirha-Gunia-Baigases motivated villagers to go to PHCs for treatment, nurturing a transition from traditional to modern medicine. This also created an enabling environment, by helping health workers be more effective since now they had support from villagers, leading to fewer causalities and deaths in district.

Advocacy with schools and other community groups

Position immunization as “a school that promotes health intervention like immunization raises the school’s status for having healthy children, because healthy children perform better and do not miss school as frequently as schools with children who either fall sick frequently or have to stay away from school because they are attending to sick siblings.”

Activities Acquire database of government/private/autonomous schools in the district from the Education Department. Meet with and seek support from Education Department on promoting immunization in schools Prepare a white paper on how immunization could be built into school curriculum, if not as a regular course, at least as extra lecture series. Print and supply RI posters to schools with advice to frame and display at strategic locations such as school canteen, class rooms, teachers’ common room. Develop health education material especially designed for schools. Use or adapt Meena materials (Meena Radio and Meena Videos) for participation by students in school. Supply Meena comics to schools through Education Department for distribution to students to carry back home.

24


Conduct social mobilizationEffective social mobilization depends on interpersonal communication (IPC), supported by mass media (IEC) and traditional-media activities. DCC will oversee all social mobilization activities at the district level.

Steps to conduct social mobilization First develop a Community Mobilization Action Plan (C-MAP) based on the microplan. Identify mobilizers (ASHA/ANM/Volunteers/theatre groups); The mobilizer must be aware of and sensitive to community values and practices. The mobilizer will need to train the community groups in participatory planning. Orient/train mobilizers especially on delivering key messages. Use supporting materials and activities, including mid-media such as stories and songs. Enlist champions: Get testimonials from those who have vaccinated their children. Supervisors for practice sessions (with visual aids) to confirm that key messages will be transmitted correctly. Put in place mechanisms to get daily feedback on social mobilization activities and focus on challenges faced.

LESSON: Adapting to community needs Any health initiative in a community is successful when there is sincere efforts in building trust and confidence in the community, understanding what the bottlenecks are in bringing any behavioural change in improving health status among the community people. The reasons for bringing change in communities should not be a sermon. The proposed messages to bring about change needs special skills/ sensitivity about their deep rooted beliefs and traditions. The reasons for changes and how to adopt should be explained clearly by the frontline staff, inviting community persons to seek questions. (Sunita Roy, Development Consultant, Gurgaon)

Make Village Health and Nutrition Days (VHNDs) as the most important health event for the community

Involve the Village Health and Sanitation Committees; educate them on immunization. Encourage community health volunteers, community based organizations (CBOs) and members of the Panchayat to attend, support and monitor the VHND. Develop IEC and IPC tools. Mobilize CBOs/women’s groups to disseminate information and mobilize caregivers. Collect feedback and incorporate changes in the subsequent VHNDs.

25


LESSON: In Tamil Nadu, India, where vaccination is provided one day a month in rural villages, the

community nutrition centre organizes children’s parades to announce the arrival of the vaccinator. (The

vaccinator is scheduled for the same day each month, but the celebration alerts the community and also

motivates and encourages responsibility on the provider’s part.) When delivery is standardized, it is easier for

parents to show up.

Ensure visits to health facility/immunization session is memorable Health workers (ASHA, AWW, ANM, MMW) can ensure that caregivers visiting health facilities return as satisfied/happy as possible with their experience. Any bad experience arising from health worker’s behavior can prevent revisits and a negative impression about immunization. Conduct IPC skills for health workers. Supervise practice of skills. Vaccination sessions should be planned according to the convenience of the community, and with their support and involvement. Find out from the community.

LESSON: In Parse district (Nepal), a single booklet gives the schedule for services in each local development community. The booklet is distributed to school teachers and others at the village development committee (VDC) level who can alert the community. The booklet also serves as a tool for checking the accountability of providers in different communities.

Use well-designed IEC material such as posters and attractive displays that are motivating and educative. Create opportunities for viewing video films if possible. Health worker should be available to answer any questions that might arise around the viewing experience. Make available carry-back handouts.

At the end of the day, the real goal of social mobilization is to create a world where immunization is demanded. The objective should be to create a comfortable, reassuring and enabling environment where immunization is welcomed.

LESSON: In India, UNICEF’s social mobilization network contributed to the increase from 30.48 million to 33.96 million children vaccinated in hard-to-reach districts between November 2002 and February 2003. A review of vaccination records in a slum in Mumbai shows that while coverage rates for DPT (diphtheria-pertuses-tetanus) vaccines were 78% in communities where primary school students made home visits to encourage mothers to bring their children to mobile vaccination units, rates were 67% in communities that lacked substantial participation. (UNICEF 2003).

Identify “Connectors” in the community. Engage them

It is important to remember that in every community there are people who are called “connectors” because they seem to know everybody and everybody knows them.

26


Connectors may not be community leaders (panchayat members or religious leaders who people know but may not like or trust). Connectors instead can be ordinary members of the community who may be trusted and loved. Such people are able to influence a community better than community leaders. Such people could be the local school teacher, or even the local doctor. Identify them. Engage them.

Mobilization through community influencers Identify and approach prominent people from the area – panchayat leaders, religious preachers. Engage and educate them on the risks and benefits of immunization. Motivate them to help in reaching out to the community. Support them with IEC tools to enable them Organize meetings in panchayat halls. Make panchayat leaders see their role in meeting MDGs (MDG 4 is immunization).

Mobilization by involving community groups

Community leaders, schools, churches, mosques and grassroots groups are critical to get communities involved. They will help transform immunization goals into action. Unfortunately, they are often not given a voice in identifying problems and designing solutions. Popular participation takes place here.

Define and roll out local mass-media strategy: for example - radio dramas, majigi or theatre troupes, banners, local media outreach Engage national and regional celebrities Urgently monitor and improve community dialogues Support and monitor compound meetings Produce simple educational module for use in schools in high-risk areas

Mobilization through NGOs/CBOs/networks Identify and list out all potential NGOs, CBOs, Women Groups, Self-Help Groups in the area. Existing village level organizations like milk cooperatives, agricultural produce committees, youth clubs, bhajan mandalis, mahila mandals, churches, and masjids can be used as peer educators. Meet and discuss with them for possible partnership. Present what they are expected to contribute to.

27


Make a training needs assessment, focusing especially on basic knowledge, IPC skills, understanding and interpretation of messages. Develop training material, or customize existing material. Involve partners in developing material. Organize training, and document. Monitor community mobilization efforts through community volunteers and monitoring formats. Assess effectiveness and correct if necessary. Support communication campaigns involving multiple channels including folk media. Ensure they have the necessary resources – IEC material, presentation equipment, etc – available with them in advance.

Mobilization through frontline health workers Hold meetings and call different field staff for sharing their knowledge and work experience. This will reduce replication of work and produce better reports. Combine their work experience. This will help in moulding the communities’ opinion and learning reasons for non-immunization. Create opportunities for ASHAs and AWWs to work together. Move both groups at the same goal. Improve internal communication. Organize capacity and skills development during mutually convenient times. Remember to take care of logistics; offer small incentives and rewards for good performance, such as a special dress with a batch, sponsorship for higher-level training, free school education for children, and similar rewards that are small but motivating. Ensure health workers have the necessary resources – IEC material, presentation equipment, etc – available with them in advance.

Mobilization by the multipurpose male worker (MMW) MMWs can especially be engaged during meetings with panchayat and religious leaders. MMWs can access hard-to-access communities where male members dominate decision making. Ensure they have the necessary resources – IEC material, presentation equipment, etc – available with them in advance.

LESSON: The child-to-child programme in India Initiative started in Mumbai for Polio by training a group of school children (10-12 yrs old) to convince targeted families in slum areas to give their children polio drops. In another programme, school children (10-12 yrs old) were taught song, dance, drama on TB and they performed at a function where parents were invited. Children distributed TB information and referral cards. Parents from the community where the school child was from were offered incentive of 25% discount in medical bills.

28


Develop IEC/IPC tools to support community mobilization While community mobilization is primarily IPC and is the tested approach to mobilize communities to know about, understand, and adopt routine immunization, the messages that the mobilizer gives can be greatly enforced when supported by strategically developed mass media and IEC tools. Development of IEC/IPC tools should be based on the C-MAP developed for each district by the DCCG..

Use posters, booklets, flip charts, flip books, FAQs, videos, audios to evoke curiosity, engage in discussions and impart knowledge. Use print IEC material as appropriate to create visibility. The Government of India has developed IEC prototypes on RI, with guidelines on how to use them in the most effective manner. (See Section 2 on Guidelines on IEC) Produce, distribute and display IEC materials during periodic events like Nutrition or Breastfeeding week/ World Health Day/ AIDS day or community exhibitions/school events, and to some extent, counselling as in home visits or on Mamta days. Organize community events such as street-theatre, drum beating, flag hoisting, rallies, using public address systems. But also ensure there is always someone available to answer questions if any. Create festive environment during and at immunization outreach and VHND sessions. Motivate community leaders to participate in the events, join the rallies. Monitor community mobilization efforts closely to detect the right messages are being delivered and understood. Document and evaluate. Whatever the delivery approach, information to community about location and timing is vital. Equally important is that services must take place as announced. Be as creative as possible; but always remember social norms and beliefs.

LESSON: Use of Pictorial Tool for Communication (Jharkhand) Krishi Gram Vikas Kendra devised pictorial tools for the Ranchi Low Birth Weight Project to educate illiterate tribal populations on healthy habits during critical life states. Sahiyya, a voluntary female health worker, delivered health messages using pictorial tools i.e. immunisation annual calendar, a tri-colour food chart and a registration booklet for pregnant women and children.

29


Some innovative strategic ideas 1. Strategy of recognizing performance and achievements of

frontline workers to sustain their hard work and motivation Frontline workers in Madhya Pradesh have shared that while financial incentive does help them, what they look forward is to appreciation by the administration. Appreciation certificate awarded by District Magistrates/Collector on State Day, Republic day celebration, etc are achievements that they would take pride in and display it at sub centres or in their house. This recognition is also viewed as an acknowledgment of their work by the Department and helps establish their credibility among the community members.

2. Strategy of celebrating completion Completion of vaccination as per schedule can be made a cause for celebration. A central communication focus is to reward individual parents for finishing a child’s series, and communities for covering large number of children by a particular age.

3. The Immunization Card as a strategy The child’s immunization card (or Mother and Child Health card) is the premier communication tool. The card is a concrete link for the mother to services at her place of delivery. It can also be presented during school admissions as a certificate of completion.

LESSON: Some successful strategic approaches used by states West Bengal: Involved additional workforce: Field-level NGOs hired part-time ANMs (retired) and organized outreach camps. Adequate supervision and monitoring helped increase coverage.Orissa: Created additional vaccine storage points. Lobbying by an NGO was able to increase number of ILR locations. Health staff has to travel less distance.Jharkhand: NGO hired additional ANMs, and created VHCs. Catch-up rounds and social mobilization was carried out through nukkad-nataks (street theatre).Andhra Pradesh: Identified gaps through baseline survey, did capacity building of health staff, ensuring better logistics, fixed easy immunization sessions, involved local women/youth groups.Haryana: Used local NGOs in catalytic role.Rajasthan: Promoted due lists. Delhi: UNRC trained women’s health groups and community link volunteers did community mapping, charitable hospitals, took support from local councillors.Multiple states: Converged ICDS and RCH services to provide fixed day, fixed sites immunization and counselling services.

30


Monitor and evaluateSuggested monitoring activities for communication

Conduct regular spot checks of materials distribution in the field. Hire a media monitoring company or recruit volunteers to determine if planned programme activities are being implemented according to set schedules. Review and document feedback from the field (from supervisors, health teams and caregivers) regarding what materials are present and sources of people’s information Monitor key media channels

NOTE: See Annexure 1.3 for a monitoring and supervision checklist developed jointly by WHO+ UNICEF +USAID.

Monitoring methods Conduct exit interviews with caregivers at vaccination sites or door-to-door to determine which messages they received and their knowledge, attitudes and practices regarding routine immunization services Hold focus group discussions between rounds or after a campaign, including questions on service delivery, social mobilization and communication messages (reach, comprehension, impact). To the extent possible, document the achievements of and lessons learned from social mobilization, advocacy and programme communication activities. Gather photos, anecdotes, testimonials, press reports and media coverage.

Evaluate impact M&E strategy must focus on three kinds of evaluation indicators*

Process evaluation (process indicators) assesses how well a BCC plan has been implemented and to adjust communication activities to meet the behavioural objectives. For example the number of target audience members exposed to BCC activities; the type and amount of resources spent; media response; meeting of deadlines on material production/distribution/media broadcast schedule; production of deliverables; printed material distribution and estimated number of viewers; number of community meetings/home visits; number and frequency of radio and television PSAs broadcast.

31


Output evaluation (output indicators) refers to early results of the BCC interventions. For example: Changes in knowledge and awareness regarding the importance of immunization, eligible ages, vaccination sites, date and time; intended audience participation, inquiries, and other responses; changes in behavioural beliefs, attitudes and perceived benefits; perceived risk and severity; normative beliefs, perceived social pressure or social support among parents to take their children to the vaccination sites.

Outcome evaluation (outcome indicators) to assess the effectiveness of a BCC strategy in meeting its stated communication objectives. For example: By the end of the community mobilization, % of parents/caregivers have given informed consent/approval and brought their children for vaccination.

*NOTE: Indicators must be included during the stage of development of the communication strategy since they will serve as baselines to measure outputs and impacts later.

Types of Indicators

Level of change Examples of Indicators

Impact 10% increase in RI coverage 2012.

Outcome % of mothers taking their new born for immunization as per schedule % of workers appreciated by mothers for providing info on need for immunization

Output % of mothers who can agree there is a need for immunization.

Process Number of community meetings conducted. OR % of community members (caregivers/others) reporting participation in event. Number of radio spots aired. Number of volunteers trained (by gender, age)

32


Prepare for managing crisis (AEFI)An Adverse Event Following Immunization (AEFI) is an unfortunate event. Most AEFI sound more serious that they are because of poor communication within the system. To handle an AEFI effectively, it is best to be prepared in advance. But ICCG/DCCG must be well prepared. ICCG must be constantly updated by DCCG during all AEFI cases.

Internal communication is most important during an AEFI. Be ready to respond promptly and effectively in case of occurrence of any AEFI. Set up a communication plan between the AEFI committee members and those working on the ground. All ANMs/ASHAs/AWWs and MOs must:

o Be sensitized to recognize and report AEFI promptly. o Know what to do in the event of an AEFI and the location of the nearest AEFI

treatment centre. Develop single-page reference material for ANMs/ASHAs on what to do during an AEFI, who to contact, etc Organize IPC training for ANMs and ASHAs on what to say to parents about AEFI, during vaccination sessions, or during door-to-door IPC Ensure District AEFI committee is functional and involved If an AEFI occurs, get information out as quickly as possible. (The public needs to know that you share their concerns, that the situation is being investigated and that you will keep them informed) Have a trusted spokesperson identified in advance to deliver messages during an AEFI. This spokesperson may not necessarily be the senior-most person in the district. Ensure that this spokesperson has been trained in media handling during AEFI. If not organize media-handling skills training in advance. Call partners meetings and discuss how messaging must be communicated during an unfortunate AEFI. Prepare and share a Message Sheet. Demand for information increases from many quarters – be prepared with information! Coordination is crucial – take charge! Prepare a coordination plan. Constantly update it when people move out of the system and new people come in. Workload increases – keep advances resources ready to quickly access the resources!

33


Media communication guidelines during AEFI During an AEFI, the media likes a fast response, accuracy and simplicity, statistics with explanation, context (part of a wider picture), comments or explanation from the highest authority, and multiple sides of the story. The AEFI Committee/Immunization Programme Managers may follow the guidelines given below for effective management of media during a crisis. Effective communication with the media includes efficient coordination with the field staff, a plan, trained personnel, a budget, and practised responses to potential issues around AEFI. It should be in place as part of the on-going communication support to routine immunization programmes.

Prepare a media plan in advance A good media plan prepared at each district level consists of the following:

A database of journalists: A list of print and electronic media journalists covering health (local, national, international) with contact information. Always use a database where updation can be done immediately in the master copy. Mention “updation date” somewhere on the page or the file name for easy recall. Update quarterly any changes in the media list.

Information packages: Keep media informed through email or hardcopy by sending regular updates on any plans, programmes, decisions, etc. Sensitize media about health aspects like benefits of immunization and its impact globally and nationally. Prepare monthly or quarterly updates. An information package may contain the following documents both in hard copy and stored on a CD:

o Frequently Asked Questions (FAQs) on immunization in general, for specific disease, and AEFI;

o Fact Sheet or a Technical Brief on a specific vaccine preventable disease; o Recent updates – progress made in India and outside – and a few case studies; o Graphs and illustrations; o Photographs; o Contact addresses of spokespersons (experts) that media can talk to.

NOTE: Please remember to check and permanently remove all old and outdated material from this information package.

Media Release: The draft media release must specifically answer who, what, when, where, why, and what action is being taken. Also remember to:

34


o Mention the name and contact details of the AEFI Committee (on the top), and the name and contact details of the spokesperson. The AEFI Committee may also recommend another name such as a medical expert) for further details should journalists have more questions (at the end). Keep these ready. Mention a “for more information, contact AEFI Committee” (with the relevant person’s name) at the end of your communication with media so that the media can refer to the relevant person in case of any queries.

o Identify in advance an appropriate spokesperson (or several spokespersons in the different agencies). Share contact details of spokesperson(s) with all concerned focal points at the district, state and national levels. This limits the possibility of conflicting messages coming from different sources. Ensure spokesperson(s) has experience or some training in dealing with media.

o Organize regular orientation workshops and field visits for journalists. This will help them achieve a better understanding of immunization advantages as well as the complexities of an immunization programme. Orientation workshops and deliberations will also help to identify in advance the kind of questions or concerns that journalists specifically have. Always take note of all proceedings and discussions with journalists. This will help to be prepared with appropriate answers when required.

Prepare messages: Try to repeat the message at least once during an interview with the media. For instance, here are two effective messages on immunization in general: o Immunization is the most cost-effective health intervention. o Immunization is the right of every child.

Some more examples of messaging specific to an AEFI situation 1. Benefit of immunization in preventing disease is well proven. 2. It is very risky not to immunize (risk of disease and complications). 3. Before the introduction of vaccines, vaccine-preventable diseases caused millions of

death and/or disability. That situation would return without continued use of vaccines. 4. Vaccines do cause some reactions, but these are rarely serious and hardly ever cause

long-term problems (have data ready and available to substantiate this fact). 5. We have a well-established immunization safety surveillance in place. Immunization

safety is very important, and even the slightest suspicion of a problem is investigated. 6. The AEFI is currently being investigated, but is likely to be coincidental/due to a local

problem (depending on type of event), and the immunization programme must continue to keep the population safe from disease.

35


Reach out to hard-to-access areasAs always with issues of scale, the problem is not just to reach more children, but to reach those who are different from the majority and face special barriers. Those who are left out are likely to include remote or mobile populations, ethnic or religious minorities with special concerns about the services, high-risk children (for example girls) in high-risk families (those who face extreme poverty and/or have many children). Communication programs classify these as both the “hard to reach” and the “hard to convince”. There are challenges on three fronts: physical, social, and systemic. A uniform strategy will not work so different strategy is needed for different locations. Some tried and tested methods are mentioned below.

Mapping as a strategy Mapping helps to identify locations and distances, and how the community physically accesses various resources.

Media behaviour mapping will indicate how information within the community and from outside is received.

LESSON: Stakeholder segmentation for remote tribal areas Communities living along roadsides have access to information and government health programmes. Segmentation based on distances can help in developing an effective strategy to reach the communities living in remote areas. Majority of those who listen to radio are males; women get info through IPC. Schools provide info through the young people. Different age groups, sex, marital status, different messaging and behaviour strategy needs to be adopted. (Avinash Kumar, Insight Research Network and AMRITA, New Delhi)

Achieving success in geographically hard-to-reach areas through system strengthening

There are many hilly regions in the country, but the state of Himachal Pradesh (HP) has a better vaccination delivery system. HP has been able to overcome this challenge by increased access. Geographical (access) difficulty can be met by system improvements, adequate human resources, etc, which HP has demonstrated well. Access problems addressed with health worker training, reliable services, and motivation. It needs to be ensured that caregivers have information, followed by motivation. Engage mobile clinics for immunization in far flung areas or sparsely populated areas. Conduct advocacy with local traditional healers in tribal areas. Engage/involve them. Local NGOs need to play a catalytic role, and help people make a positive decision. Organize regular community meetings with mothers. For tribal persons, comics and cartoons are easily accepted, using their culture and vision to promote the health ideas. Identify positive deviance from within communities and highlight them.

36


Case Study: Strategic communication for immunization in urban slums The following conclusions are based on a study of Chotton Ki Asha project which was implemented by HOPE Foundation, an NGO, with the help of USAID. The project was implemented in Sonia Vihar in Trans Yamuna Area of Delhi. Sonia Vihar is an illegal settlement of migrants having a population of about 2 lakh. The following strategic activities were carried out:

At the community level, 800 community volunteers were trained by Community Health Promoters and Community Organisers who were part of Project staff. The Project staff in turn was trained by experts from reputed organisations. The main strategy used was BEHAVE Framework (see Annexure 2.9). This framework includes identification of target population, definition of activities and outcomes. These were linked with critical target indicators. For each kind of necessary behaviour, facilitators and barriers were identified and this was based on formative research, barrier analysis, focus group discussion and key person interviews. Based on analysis, a feasibility list of activities which could be carried out was prepared and implementation framework was developed. Behave framework was linked with the project plan in such a way so as to identify minimum behavioural requirement which would identify a person to be moving from negative deviant to positive deviant. These behaviours were identified for all Project interventions. The activities carried out included:

o Interpersonal communication o Community education through group meetings o Street plays and puppet shows o Jingles and songs o Print materials like posters, use of games like snakes and ladders, wall writing o Audio visuals o Health melas

Some of the innovations included using cycle rickshaws for display of posters and relaying messages and use of mobiles (m-health) for communication with families. The project staff developed and implemented quality standards for service delivery, trained staff and ensured adequate provisions. Staff members were motivated to ensure patient-friendly behaviour at all times. Each message given was pre-tested and context specific and sensitive to local culture. The messages were coined in different languages to meet needs of different groups. To integrate approaches, advocacy was carried out with stakeholders such as the Health Department, ICDS, NGOs and private players. To ensure cooperation from the minority community, visible and influential leaders were identified and integrated into the programme. The activities were monitored in terms of:

o Actual activities carried out against plan. The immediate output in terms of target audience attendance (both numbers and age groups).

o Change in programme indicators o Periodic community based surveys were carried out to specifically measure behaviour

change as per set formats. Over all the BCC strategy used by HOPE Foundation in this project appears to be very effective and worth adopting in similar situations especially for provision of integrated health care as envisaged under NRHM.

37


Communication for introduction of new vaccinesKEY STRATEGY: Position new vaccine as “new and improved” now offering extra protectionfor the child.

Communication with caregivers 1. Most parents seek immunization in the belief that it is good for their child, and do not

usually know or seek detailed information about the vaccines and diseases prevented.

2. Parents do need to be reassured that immunization is good for their child; effective at preventing disease; and the safest way to protect their child against that disease.

3. Communication for immunization can also position it as ‘public good’ aspect: that it is a key parental role, like love of your child, and that it is normal practice, and essential part of growing up safely, as well as a civic duty to each other.

4. Parents may have concerns about getting an extra vaccine, because of potential side effects and additional discomfort for the child. Parents will need reassurance that the extra vaccine, especially if injected, may be safely given at the same visit, and will provide additional and timely protection to their child. And that the pain of two injections is not double that of one injection – but it would be if given at a separate visit. (The two injections cause a similar stress response as one injection, if there’s minimal time delay between the injections.)

5. Parents also need to be told about the (usually) five visits for immunization in the first year of life and the importance of early protection.

6. At each visit parents need to be told the time for the next visit (or congratulated when the child is fully immunized) and how to care for the child after the vaccination.

Provide vaccinators with training on counseling about new vaccine 1. The limited evidence available to date shows that it is vaccinators rather than parents

who need to be persuaded about giving an additional injection at the same visit for early protection. When a vaccinator is competent and comfortable in giving multiple injections at one visit, they can easily persuade the parent that this is the right thing.

2. As a key ‘messenger’, vaccinators require special attention and support to communicate useful information at the time of service delivery. Preparations for introducing a new vaccine should include training and mentoring practice of vaccinators on interpersonal communication (IPC).

38


Information that caregivers/parents need to know regarding a new vaccine (Excerpt from: “Good Practices and Challenges– communication for introduction of new vaccines,” Michael Favin, The Manoff Group, Presented at UNICEF Communication Consultation, December 2009.)

Parents MUST know:

That immunization is important (good) for their children’s health. When and where they should bring their child for his/her next vaccination, including actual service hours (and have confidence that vaccinator and vaccines will be available). That a new vaccine means that their child will receive more protection, usually without any extra visits. That it is safe to receive an additional vaccine and more than one injection on the same visit. There are not likely to be any important additional side effects (discomfort) because of the additional vaccine given on the same visit.

Parents DO NOT need to know:

Details of vaccines and disease prevented, unless desired. The immunization schedule (by heart).

Additional considerations for communication planning Preparedness needed to respond to allegations/rumours and AEFIs and build parental trust in vaccinator and system

IEC for Pentavalent vaccine introduced in India IEC material for Pentavalent vaccine – posters, hoardings, press ads, and FAQs – are available with the Immunization Division, MoHFW. Pentavalent vaccine has been introduced in Tamil Nadu and Kerala.

Poster FAQ booklet

39


Campaign communicationCampaigns are a reality of immunization programmes, and pose great challenges for communication managers. Demand creation is not the only communication task of a campaign. Clarity of message in the context of the entire immunization schedule is critical. Campaigns can provoke confusion among caregivers with unplanned messaging. This confusion can also feed into rumors. It is therefore critical that communication planning for campaigns is done carefully. The responsibility of the campaign advocacy at the national level always lies with the Interagency Coordinating Committee (ICC). At the national level, immunization planning begins with the ICC and its various working groups at the state level. At the state level the responsibility is with the State Operations Group (SOG)/ or the ICCG.

Centre vs State roles Campaigns often have national leadership promoting decentralized implementation at the state level.

For the national campaign, Centre supports with mass media, for example, and production of IEC materials is coordinated at state/district levels.

Clear guidelines (and prompt funding) are necessary to assure campaign message consistency.

Actual implementation is at lower levels. Materials must be appropriately adapted. This also avoids the familiar bottlenecks associated with centralized distribution.

Involve local leaders in planning interventions as well as mobilizing populations. Local planning need not be left only to remote ethnic groups.

Elements in campaign communication Communication micro planning (weekly plans) Dividing responsibilities, and establishing an effective internal communication system Production of material and distribution logistics (See Annexure 1.9 for IEC planning) Advocacy for support Engaging the media Conducting awareness and drawing commitment Special messaging (positioning the campaign as an opportunity not to be missed) Working on resistance

40


Capacity building of service providers and supervision of IPC Preparedness for crisis Monitoring and evaluation, including programme reviews

Communication planning for campaigns Work backwards, start with campaign date Weekly Planning (4 weeks, but 28 days), include daily activities

o Segment desired audiences o Prepare inventory of communication resources (IEC material, mass media,

training material) o Decide channels and vehicles to use o Combine and sequence communication activities o Prepare for crisis communication o Monitor and evaluate communication activities

Campaign messaging Design messages that reinforce/clarify messages related to routine immunization visits. Use training opportunities in campaigns to improve IPC skills. Prepare health workers and local leaders for common rumors; supply Q&A and guidelines related to dealing with rumors.

LESSON: Campaigns in the context of completion and timeliness

For parents, campaigns can cause confusion about what completion of the series and timeliness mean. For instance, Measles catch-up campaigns targeted children up to 10 years of age. None of these extra vaccinations are marked on the child’s card. This may confuse the parent. For example, if a vaccinator comes to the house for one round, the family may decide that all other important vaccinations will be brought to their door. Although vaccinators in a campaign setting have little time, they should explain to each parent that they still need to complete the series. They should also explain that families must return to their regular delivery system for additional vaccinations. Community volunteers, if well-organized and -oriented, can also counsel caregivers at campaign vaccination sites.

Community mobilization Conduct social mobilization (using IEC, TV, radio, national press, and IPC) early enough to enhance population awareness and interest. See Annexure 1.9 for IEC planning.

41


Involve IAP and private practitioners at state and district level through workshops and meetings. See Annexure 1.10 for a sample of an advocacy letter. Notify private schools with sufficient time and information. Send letter signed by health officials and relevant pediatricians Advocate with other partners to gain support Conduct local miking and announcements of location of post the day of the activities. Ensure adequate visibility of session sites through IEC material and other material (Give a festive look)

Capacity building

For a successful health campaign, capacity building of all stakeholders in campaign communication is highly important and necessary. Communications during a campaign can make or break a campaign. From the level of programme managers to the level of vaccinators and mobilizers in the field, one needs to undergo communications training. Given below is a list of areas where training will be necessary:

Proposed contents in an advocacy kit for media and other partners 1. Frequently Asked Questions (FAQ) on measles

1.1. Technical information, data and facts. 1.2. Why a measles catch-up campaign? What is the government planning to do? 1.3. What will be the socio, economic, political impact of the campaign?

2. Visual aids 2.1. Audio-visual, films, pictures

3. One-on-one experience sharing (where possible, during larger advocacy gatherings) 3.1. Experience from the ground, experts talk

4. Development of key messages 4.1. Key message for central ministries:

4.1.1. Life cycle of the child/Holistic development of the child 4.1.2. Global scenario

NOTE: See Annexure 1.10 for a sample advocacy letter “seeking support from medical practitioners/institutions/associations” as a partner for measles 2nd dose catch-up campaign.

42


Examples of campaign IEC material Prototypes of the IEC material for JE, Measles 2nd catch-up, Polio, Immunization Weeks campaigns are available with the Immunization division, MoHFW. These prototypes have been widely circulated in all states. On demand, copies can be provided.

JE Campaign IEC

Measles Catch-up Campaign IEC

Polio

Immunization Weeks

ANNEXURES FOR PART 1

43


45

Annexure 1.1: Channels and vehicles for message delivery Mass Media 1. Radio (including FM channels) 2. Television 3. Newspapers 4. Booklets 5. Posters/Banners/ Hoardings/Wall writings 6. Flyers/leaflets 7. Loud speaker announcements 8. Miking 9. Videos/Films 10. Press kits 11. Media guides 12. Town criers 13. SMS/Internet/mails/Phone calls Typical Materials Typical Formats1. Development and use of logos, leaders' statements 2. National addresses by presidents and other high-level

officials 3. Publicity by celebrities, including goodwill

ambassadors 4. Press conferences 5. Newspaper editorials 6. Public advertising: calendars; banners;

hoardings/stickers/wall writings 7. Promotional materials: t-shirts, hats, banners, bags,

and pens 8. Announcements via megaphones, microphones, loud

speakers

1. Different radio/TV formats (interviews, success stories/footage from countries, phone-in questions or reports from the field, talk shows, guest of the week, press conferences, panel discussions; advertisements)

2. News coverage 3. Interviews with leaders, satisfied

caretakers, and experts 4. Public service announcements, spot

announcements

Often good for Not usually good for 1. Creating general awareness 2. Giving the basic facts 3. Giving information a sense of importance and

legitimacy 4. Popularizing and reinforcing messages 5. Can encourage & pressure people to join in 6. Giving short, key messages on schedules, dates,

location, basic information (local language posters). 7. Reaching many people simultaneously 8. Reaching rural communities (local radio) 9. Reaching health workers and urban and peri-urban

audiences (radio and TV) 10. Reaching elites (including politicians and decision-

makers) and middle class and their household help (gardeners, housekeepers, nannies)

1. Facilitating interaction with audiences 2. Giving detailed explanations 3. Responding to individual questions or

concerns 4. Providing appropriate messages for people in a

variety of circumstances and with different levels of intention to act

5. Being understood by all members of the audience (dialect, vocabulary, and/or images)

6. Saving expenditures (mass media is expensive to produce, and broadcast time may be a huge expense; posters are logistically difficult to distribute in timely way and are not always seen by many of the intended audience).

7. Reaching key groups (the illiterate, those without radio access, etc.)

Interpersonal Communication (IPC)IPC can be very effective in influencing and reinforcing positive behaviour change but requires thorough advance planning, particularly of logistics Typical materials Typical formats 1. Counselling cards 2. Pocket fact books

1. Visits and discussions with key allies 2. Lobbying and telephone contact with individual


46

3. Stories and examples 4. Pictorial booklets and pamphlets used for teaching

and given to target audiences to take away. 5. Photographs used to stimulate discussion.

allies 3. Inviting national or international experts to

confer with national leaders 4. Counselling at health facilities 5. Discussions with family during home visits, child-

to-parent educational activities 6. Hotline telephone contact

Often good for Not often good for 1. Supporting behaviour change (addressing obstacles

and doubts and motivating/ persuading) 2. Legitimizing, reinforcing and sustaining new

knowledge, attitudes, and behaviours. 3. Responding to questions and needs of a personal

nature 4. Identifying and filling information gaps 5. Flexible to individual schedules and needs

1. Reaching many people quickly, without extensive planning and training of many staff or volunteers, followed by good monitoring and supervision

2. Providing clear information or messages if communicators are not well trained and oriented.

3. Preventing communicators' biases from entering communication

Mid-media (Group Channels)1. Group discussions 2. Seminars/workshops 3. Religious services 4. Meetings 5. Performances 6. Celebrations 7. Rallies Typical materials Typical formats 1. Slides, film strips 2. Announcements in places of worship, rallies and

processions 3. Fact books and program briefs to stimulate questions

and discussion 4. Role plays 5. Demonstrations

1. Public meetings 2. Religious events 3. Traditional ceremonies 4. Sports events 5. Exhibitions, fairs 6. Travelling/community theatre 7. Traditional music and dance performances

Often good for Not often good for 1. Facilitating interaction for sharing ideas 2. Explaining details and responding to questions 3. Legitimizing messages and building consensus 4. Providing support for changing attitudes and

behaviour and maintenance of new behaviour 5. Addressing rumours and misinformation 6. Using audience members as guides/ mobilizers 7. Using local languages 8. Improving trust and demand for health services (if

health workers with serve as communicators).

1. Ensuring uniform message content 2. Responding to queries of personal nature 3. Encouraging the active participation of certain

groups such as minorities 4. Encouraging use of public health services (if

health workers have bad attitudes) 5. Reaching large sections of the population at

the same time 6. Reaching those people who won't actively

participate or ask questions

Note: The BCC Strategy for NRHM in Uttar Pradesh gives some practical approaches to BCC and recommendations highlighting immediate and long term plans.


47

Annexure 1.2: Immunization IEC/IPC planning format*Name of District………………………….No of Blocks…………No of Villages…………………………….

Sl No

Activity/Material Target Group

Quantity Scheduled Date of Completion

Person responsible forverification

Total budget In Rs

Remarks

Print material

Poster

Handout/Leaflet

Advocacy letter

Folders

Any other

Mass media material

Local cable programs

Radio programs

CDs/DVDs

Video vans

Newspaper ads

Banners

Hoarding

Any other

Mid-media (Traditional media)

NukkadNatak(Street theatre)

Rallies/processions

Wall paintings

Miking

Any other

IPC

Training

Workshops

Compound meetings

Any other *You may create separate charts for IEC material, mass media, mid-media, and IPC activities (depending on the variety and amount of material you are producing), or you may add to this chart itself as indicated above.

This is an illustrative chart, so feel free to modify. If you wish, you may also add extra columns to the formats above should you want to use some other information. The experience is that more formats we have, and the more columns there are in the formats, the lesser they are filled.


48

Annexure 1.3: Research, Monitoring and EvaluationPurposes Formative Research Base- Midline-Endline Evaluation Monitoring

What kind of research? Definitions:

It is an investigation to study and assess audience’s interests, needs and priorities as well as the context in which they live for programmatic decisions.

It describes the condition or performance of subjects prior to the intervention, against which progress can be assessed or comparisons made.

A study conducted at the end of an intervention (or a phase of that intervention) to determine the extent to which anticipated outcomes were produced.

It is a regular collection and analysis of information to assist timely decision making, ensure accountability and provide the basis for evaluation and learning.

What do we intend to achieve?

To understand the context in which the programme will be implemented; 2) identify specific behaviours of concern; 3) learn the determinants of these behaviours; and 4) identify institutional, communication and social resources that are available to the program

Establish the initial status of key indicators, which serves as a basis for comparison with the subsequently acquired data.

Compares the baseline with the results obtained to establish the degree to which the programme is achieving the intended objectives: short-term effectiveness or long-term impact

Evaluation design may include: Pre-post or periodic follow-up data collection or comparison to an outside group

-Tracks inputs and outputs and compares them to plan

-Identifies and addresses problems

-Ensures effective and efficient use of resources

-Ensures quality and learning to improve activities and services

-Strengthens accountability

-Improve program management

When is it usually carried out?

Before the strategy design or during the early stages of the program

Evaluation is periodic: Monitoring is continuous

Baseline should be conducted before the project is implemented

It can take place at the end of an intervention or a phase of that intervention.

What question should we ask?

What is the problem? Why is it happening? Is C4D needed? Who need to practice the behaviour? Who supports/hinders the behaviour? Why? What other factors influence the practice? How, when and where?

What are the existing communication practices, networks and channels we can use to influence change?

Where are we now in relation to the situation we want to change?

What are the current indicator levels/values before intervention

-Does the programme achieve the intended objectives? To what extend?

-Does BCC intervention contribute to the programmatic goals of the organization, and to what extent?

-Does BCC intervention impact vary across different groups of intended audiences, geographic areas, and over time?

-How effective is the BCC interventions in relation with other interventions?

To what extent are planned activities actually being realized?

Are we reaching and interacting with the right people?

How well is the information provided and dialogue supported?

How well are the activities implemented?

What early signs of progress toward outcomes can we detect?

Purposes Formative Research Base- Midline-Endline Evaluation Monitoring

Which methods can we use?

Desk review Focus Group Discussion In-depth interviews (IDIs) Trials of Improved Practices Social mapping SurveysObservations:Participant observation and open-ended Focus Ethnographic Survey (FES)

Survey (KAP)

Focus Group Discussion (FGDs)

In-depth interviews (IDIs)

Observations (preferably, structure observations)

Opinion Polls

Service delivery records Participant group satisfaction Tracking surveys Media coverage analysis Inventory tracking Focus Group Discussion In-depth interviews (IDIs) Observations (structure and open-ended)


49

Annexure 1.4: M&E Format

Monitoring and Evaluation Format

District name:…………………………………… No of Blocks…………………………………….

Objective Process (Output) Outcome

Indicator Means of verification




50

Annexure 1.5: How to organize a media conferenceHold the Media Conference when you have

A newsworthy story. New information relating to a big story being followed by the media. A statement on a controversial issue. (please choose this carefully) Participation of high profile speakers or celebrities. Release of important new findings or research data. Announcement of something of local importance – such as campaign for measles 2nd dose of vaccination.

Location and Set-Up

A central well-known location convenient for journalists and appropriate to the event. Avoid a room which is too large, not well lit and has echo in sound – it gives the appearance that few people attended and does not allow quality recording. Make sure the noise level of the room is low. Reserve space at the back of the room for television cameras, possibly on a raised platform. Reserve an additional quiet room for radio interviews following the press conference. Ensure light and sound systems are in working order. If possible, have a fax, phone and internet connection available. If you are holding the conference at a district level, this will ensure that your journalist who may be low in resources will complete the story and send from the location of the conference itself. Make sure there is a podium and a table long enough for all spokespeople to sit behind. Names of all speakers should be legibly printed and displayed before each speaker. Consider displaying large visuals such as the measles immunisation poster and duplicate the same pattern on the background banner, notepads for media, bags for media and press kit. Prepare a "sign-in" sheet for journalists so you know who came and where to find them. These should capture their mobiles and emails clearly. Decide if you wish to serve coffee and tea, or light snacks, following the event. It may serve as an informal means of getting to know your reporters.

Timing

Work out a timetable to ensure that everything is ready when it is needed. Hold the event in the morning or early afternoon of a workday. An ideal timing would be eleven in the morning for instance. Check that you are not competing with other important news events on the same day. Start the event on time – avoid keeping journalists waiting. Distribute material prior to a news event: you can use an embargo to prevent journalists from publishing before the event. Wait until the event to release important information to create an element of suspense. Include quotes of main spokespersons to ensure the correct message is disseminated and to avoid any misquotes.

Possible Materials

Media release and Press Kits. List of news conference participants (who was on the panel and their titles). Copies of speeches. Immunisation data in your state/district.


51

English and translations (into local language/dialect) of fact sheet and FAQs on immunisation and IEC guidelines. Video footage of campaigns/video films as provided in the Training of Trainers programme. The footage will be especially useful for the TV journalists. Radio Jingles in local language that can readily be used by radio journalists

Inviting Journalists

You can invite by phone or by fax or post, but a telephone call first is always a good idea for ensuring that important papers find the right journalist. Find out which journalists report on issues relating to your event or issue. Keep an up-to-date mailing list or database of journalists. Focus on getting the most influential media to attend. Get your event in journalists' diaries 7 to 10 days before the event. Always make a follow-up call after the invitation has gone out to check that the right journalist has received the information. Consider providing general background briefings to important journalists prior to the event, without disclosing your main news story to them. Consider offering "exclusive" angles on the story to key media. These can be in form of field visits during the campaign for select media. If you already know some journalists well, involve them early and fully.

Preparing Speakers

Select appropriate speakers. (This seems obvious, but sometimes people are asked to speak because they have certain positions, not because they are good at speaking and know the issues). Select strong speakers who are articulate, authoritative, engaging, and clear. Brief speakers carefully on the main message of the event. Prepare speakers in advance on how to answer difficult questions. Offer to provide speakers with Question and Answer material. Try to hold a meeting to brief all speakers before the event. Ideally, each speaker should present for only 3 or 4 minutes. Have each speaker make different points. Make sure that each speaker makes one or two important points ONLY. Keep speeches short and simple, aimed at a general audience and avoid technical jargon. Select a moderator who will manage questions from the floor after the presentation. Encourage lots of questions. Keep answers to questions short.

Follow-up

Within a few hours of the conclusion of the press conference, fax or deliver information, photographs and video to important journalists who were unable to attend. Make sure to take any follow-up calls from journalists. Ideally the media officer should be easily accessible for all follow-up questions and clarifications on mobile. Gather press clippings of the coverage which results from the press conference and distribute this to important partners and policy makers. Document all communication activities including the press conference for capturing all important media queries.


52

Annexure 1.6: Prototype of TNA FormAssessor/Interviewer details Name: Designation: Years of experience: Education: Geographical area of work: Date:

Target groups and issues discussed (ask health worker and fill in the table; add more rows as necessary)

Target Group Issues discussed

Knowledge level

Subject Good knowledge, comfortable to discuss

Need more knowledge, find them uncomfortable to discuss.

At a given instance, how much time do you usually spend with an individual when you are communicating?

No of minutes:

No of hours:

Would you like to spend more/less time? What are the factors that prevent you from doing that?

Which of the following do you find as the best place/occasion to convey correct health message to people?

Rate from 1 (best) to 5 (worse).

Home visit RI Session/ VHND

Small group discussions

Public meeting Any other (Please specify)

How do you mobilise the community for accessing services at the:

PHC CHC AWC Sub-centre Immunization point

Any other

What aids/materials do you use when communicating and how do you find their use?

Material used Issue Discussed I find this easy to use because I find this difficult to use because

If you are given an opportunity to increase your skills for communicating, what are the skills you will like to learn?

Patience Hearing and listening

Explaining Maintaining eye contact

Speaking to large groups

Management of groups

Analysis Mobilising audiences

Making an important point

Giving options/finding local solutions

Giving local examples

Any other


53

Annexure 1.7: Key questions for monitoring and supervision of immunization sessions Sl No

Questions Answers

Observations of health staff and vaccination teams What information is communicated by the

vaccinators and mobilizers during the immunization activities? (Differentiate between facilities, mobile teams, and door-to-door vaccinators, as appropriate.)

Do health workers remind caretakers to bring eligible children back for the second round and for routine immunization?

Do health workers welcome and thank caregivers for bringing the children?

Do health workers ask caregivers if they have questions about immunization?

Do health workers ask caregivers to inform and encourage other members of the community to have their children vaccinated?

Are vaccination teams actively looking for and reporting zero-dose (i.e. unvaccinated) infants?

Questions for caregivers How did caregivers hear about the

immunization schedule/campaign (through what channels or media)?

When did the caregiver receive the information about VHND?

What encouraged the caregiver to have the child vaccinated?

Is this the first time that their child has received vaccination??

Does caregiver know why vaccine is being given?

When should the caretaker bring the child for his/her next routine vaccination?

Does the caretaker know anyone who has not brought their child to be immunized?

Questions for community leaders and media How have they supported immunization

sessions? What messages have they provided on

routine immunization sessions to their communities?

Do they know when the next round of the immunization session or campaign is?

Any other important information that needs to be shared.

Signature of Assessor


54

Annexure 1.8: A typical IPC role-play training session

TIME

60-75 minutes.

SESSION TOPIC

Developing IPC skills of participants (health worker).

OBJECTIVE

For participants to learn actual interpersonal and motivational skills.

MATERIAL

Role plays case studies.

PROCESS

1. Start with a role play. Two groups (depends on no of participants, but not exceeding 4-6) should have been selected in the morning. 2. Take them out of the hall. Share with each group a story plot or situation (see example of a Situation given below). Instruct them to

prepare a role play based on the situation. Allot them 10 minutes to present it. Just before the role play, the trainer will come to the hall and assign the rest to:

o Observe the role play. o Take note of the Health Worker/Volunteer’s role especially.

DEBRIEF

After this round of 2 role plays hold a debriefing. Ask the following questions.

1. What did you see? 2. What obstructed the communication between the Health Worker/Volunteer and the family? 3. How can this interaction be improved?

BRIEF

This is the time to brief the participants on the various attributes and skills an animator should possess and use when dealing with non-acceptors or reluctant families especially and the community at large.

ROLE PLAY (Example only)

SITUATION I

This is Rahmat Ali’s house. Rahmat Ali is a weaver. He receives raw cotton from traders and delivers finished product to them. Rahmat is sitting on a mat, busy weaving a cloth. His daughter is helping him on the loom. His wife is also present in the house doing the household chores. The Health Worker knocks on the door….

Intensification of Routine Immunization: Communication Operational and Technical Guideline

A typical 2-day IPC training programme schedule

Adapted from “Chalo baat

Samjhey aur Samjhaayen…” (in Hindi): Facilitator guide and training manual in IPC for Health and ICDS Workers; Developed by UNICEF and Government of Uttar Pradesh


55

Annexure 1.9: Campaign IEC Planning Grid


56

Annexure 1.10: Prototype of an advocacy letter seeking support(Addressed to Medical Practitioners/Pediatricians/ Members of Professional Medical Associations)

To

………………………………….

………………………………….

Subject: Support for KhasraRakshakAbhiyan (Measles Catch-up Campaign)

Dear (Dr) _________

The state of ……………………is conducting a measles catch-up campaign as part of the national immunization programme. All children aged 9 months to under-10 years need to be vaccinated regardless of previous vaccination status or history of measles-like illness. The aim of the campaign is to cover 100% of the targeted children.

As you are aware, Measles is highly infectious disease caused by a virus. An estimated 50,000 to 100,000 children die from measles annually, making it one of the leading causes of child death. Measles can be prevented by immunizing children with measles vaccine which is safe and effective.

National routine measles vaccination coverage is 69% (DLHS-3). As measles vaccination confers immunity in 85% of children when given at 9 months of age, a substantial number of children remain unprotected even if they are vaccinated. Hence a catch-up campaign offers a 2nd opportunity to the susceptible group of children and a way to maintain population immunity against measles and sustain high measles vaccination coverage

The measles campaign will be conducted over 3 to 4 weeks. Vaccination will be conducted in schools during the first week and later in community sessions.

For the success of the campaign, your contribution will be critical. Your active participation in the following activities will be highly appreciated:

Advocating with parents to get their children vaccinated. Providing your clinic as site for immunization session Developing your clinic to act as AEFI management center and you will be trained to manage AEFIs and will be given AEFI management kits Becoming a trainer for the vaccinators and supervisors (if interested) after training at district level and Communicating the messages to your colleagues for similar involvement in the campaign.

We thank you in advance for your cooperation!

Should you have any questions, please call …………………………………(telnos) or meet………………………(Names of Immunization Officers/Medical Officers).

PART 2: TECHNICAL GUIDELINE

57

Developing the communication strategyThe first step to operationalizing communication is to have a carefully-drafted evidence-based communication strategy. Using a strategic communication framework is recommended. Any communication strategy must answer the following questions:

1. What is the behavioural change objective for doing that communication? 2. Who all are engaged (both caregivers and service providers – demand and supply)? 3. What will be the core message(s), and how does one communicate the messages using

channels and vehicles? 4. What tasks and products will be needed (ie, activities and tools)? 5. How do we pre-test the appropriateness of the messaging and channels? 6. How to monitor and evaluate the communication efforts for outcomes?

Communication Strategy Framework (SmartChart) To write the strategy, refer to the Strategy SmartChart (adapted from Spitfire Communications, Annexure 2.1). It is a framework for developing communication strategies.Use a computer so that the necessary information can be put into the specific columns. A multi-channelled integrated approach to communication is recommended as dictated by the objectives, engaging and targeting a range of influencers, so that participation is increased, gaps in communication can be reduced, and enabling environments to practise desired behaviours created.

Steps in the Strategy SmartChart The most powerful tool for developing effective communication strategies is evidence-based data. Evidence from research shapes the strategy by providing answers to the:

Main causes behind low immunization coverage and dropouts Identifying specific behaviors (actions) that will be promoted by the strategy Main barriers to and motivators for behavioural change Key audiences and influencers to engage with, both primary and influencing Setting up the communication objective Resources (especially communication resources) available to support RI


58

Key district and community-level leaders and officials whose support will be needed for carrying out the social mobilization strategy Key health staff or community volunteers to deliver messages Obstacles to overcome in conducting a campaign Communication channels to be used How to operationalize the strategy – guidance on which partners and entities should be involved, the specific time/phase of their involvement, and partners' roles and responsibilities

STEP 1: Situation Analysis A Situation Analysis has two components in it:

1. Identifying enabling factors (systems-related) for implementing an effective communication programme

2. Evidence-based behavioural factors (caregivers and health service providers) that influence demand for immunization

System analysis

Even the best communication cannot change behaviours unless the service delivery system meets the service demands effectively. A gap analysis will help identify the system-related barriers that can hamper successful implementation of the immunization programme. Both qualitative and quantitative data is required. Analyze the following system-related aspects:

Readiness by the various departments (Health, ICDS, Education) Vaccine availability Convenience of place for immunization (for caregivers and service providers) Availability of adequate and trained health workers for vaccination sessions Availability of immunization services in time Financial resources required and available

For more system-related reasons, see Annexure 2.6.For the ICCG, knowing about the systemic gaps that can hamper the implementation of the communication will help develop a realistic and implementable strategy.

Behaviour analysis

The primary objective of the immunization communication strategy is to facilitate internalizing of key messages related to the desired behaviours by both service providers and caregivers. Therefore, it is important to know what behaviours need changing and what the barriers are which prevent the desired behaviours from getting acted upon. Evidence is


59

available from surveys such as Knowledge, Attitude, Practice (KAP) findings, District-level Health Surveys (DLHS), Family Health Surveys and documented evidence from published research or programme implementation lessons learned. Follow the steps below for effective behaviour analysis.

Step 1: List out a set of desired behaviours in the two key groups: (1) Service providers, and (2) Caregivers (See Annexure 2.2 for example). Step 2: Identify key factors responsible for non-immunization in the state, reasons for dropouts and reasons for leftouts. These factors could be both system related and caregiver related. If reasons specific to the districts can be identified, this will be useful in preparing district-specific strategies. These will help to know the behavioural barriers. See Annexure2.2-2.8 for a list of key factors for non-immunization in India. Step 3: Identify reasons for low immunization in urban areas. Depending on the reasons, a separate communication strategy might be necessary for urban areas. (See Annexure 2.8) Step 4: Use a Behaviour Analysis Matrix (an example is given below) to put in the behavioural information collected in Steps 1-3.

Behavioural analysis matrix Desired Behav Actual Behaviour Feasible

Behaviour Barriers to Desired Behaviour

Motivations and Supports (Message)

Caregivers bring their children to immunization service delivery points at the ages recommended in the national schedule with immunization card

Many caregivers take their children for complete immunization at some point in time

Delay in first immunization based on practice of ‘staying in the home’ after delivery for at least one month and health workers not remembering to advise mothers

Delay in intervals between immunizations

Many caregivers could not locate their cards (although they could remember place on body and number of times their child received immunization)

Caregivers bring their children only one time to get immunization

Most caregivers take their children to get fully immunized

Follow the schedule of Immunization

Maintain the Immunization Card

Lack of knowledge about immunization

Lack of awareness of immunization schedule, place, date

Long distance to closest health facility

Worry that mother and infant could get sick if she leaves the house too early

One has to pay for vaccine

Attitude of health staff unrespectable to caregivers

Immunization prevents serious child sickness

Support of other family members for the mother to take child for immunization

Understanding of family members that mild negative side effects from immunization is normal

Immunization is free


60

Step 2: Programme and communication objective

Now that the behavioural objectives have been identified, the next step is to identify the communication objectives and corresponding activities.

Begin by writing a SMART communication objective

SMART = Specific, Measurable, Achievable, Realistic, and Time bound

It is useful first to know the difference between programme and communication objectives.

Programme objective: What does the Immunization Programme (at state level) plan to achieve by the end of, say year 2012? For example, “By December 2012, immunization coverage in state/district X has increased from 61% to 70%.” This is the big programme goal for the state, the overarching objective of doing the immunization programme! Immunization programme managers must be very clear in defining what their programme objective is.

Communication objective: To achieve the above programme objective, our targeted stakeholder must practise certain behaviours. To ensure that the desirable behaviours are practised or barriers to behaviours are overcome, targeted communications will be needed. For example, “By October 2012, x% of mothers in a given community in district Y of Uttar Pradesh have been met by the local ASHA and educated about the benefits of immunization schedules.” This is a communication objective, has two stakeholders – caregivers and ASHAs. It specifies what kind of communication activities and tools will be required to ensure that ASHAs practise their behaviour to enable the desired behaviour in caregivers.

Here is an example of a communication strategy for immunization in Uttar Pradesh:

Programme goal: By 2015, 70% of children will be fully immunized in Uttar Pradesh Communication objective: Percentage of mothers/caregivers of children 0-1 year in Uttar Pradesh who strongly agree on the need for complete RI to protect their children from vaccine preventable diseases increased from 56 to 70 by 2012

NOTE: Ideally, every separate communication objective must be on a separate SmartChart, because to meet each objective, there will be a need for framing specific messages, identifying specific activities, tools, outcomes, and conducting monitoring.


61

STEP 3: Strategic Choices Target audience: This has to be carefully chosen. A target audience is one from whom a desired behaviour is expected. For example, a mother of a young child is expected to bring her child to the immunization session. She thus becomes the primary audience for change. However, especially in Indian conditions, a mother’s decision may be influenced by either the husband or elders in the family such as the mother-in-law, who may not advise the mother to take the child for the vaccination. In that event, the mother’s behavioural barrier is her husband’s perceptions or the mother-in-law’s beliefs. To enable the mother to act, behavioural change communication needs to be targeted at the husband or the mother-in-law or both. They become the “influencers”. For the sake of convenience, it will be useful to use the term “key audience” for targeted audiences. Therefore, one communication objective may have one or more key audiences.

Readiness: It is important to know the current standing of key audiences on the knowledge, attitude and practice line, because this will help guide communication messaging and positioning. For instance, if knowledge about immunization schedules already exists among the key audiences, telling them about immunization will not be received. It will be a waste of resources and communication opportunities. It is possible the key audiences have knowledge and also want to act but barriers prevent them from taking action. In that case the communication will be about removing the barriers (to build will). Therefore it needs to be decided whether the communication will be to share knowledge, build the willingness, or to reinforce the action.

Positioning: This is about tapping the important values or needs of the key audience. For example, there is greater potential for policy-makers to act when they are presented state/district data rather than when they are only given information on the benefits of vaccination. The communication must carry data. Messages: This is about what the audience would want to hear from the communication. But even when a message is heard, audience will act only when the message is positioned in an appropriate manner, ie, it prompts/motivates them to act. Some key messages for caregivers are given below in the box.

Messages are of two kinds:

1. Content messages: This is what the message must say. Statement such as “To have lifelong protection against deadly diseases, newborns should begin receiving immunization immediately after birth.” (See box below for a list of key messages in immunization.) This is what the message must say on all communication material,


62

but if they are presented in this way, the messages may not motivate the targeted audience to act.

2. Motivating messages: These are what the audiences derive from hearing/reading the message. It is the carry-back home feeling, or knowledge. It is this that motivates the audience to take (or not take) an action.

Messenger: How is the message to be delivered and by whom is a critical decision. Choosing the right messenger will enable the audience to find credibility in the message and prompt action. For instance, mothers have been found to follow the advise by an ANM to bring their children for immunization even when mothers did not know about the vaccine or its benefits.

Some key messages on Routine Immunization for caregiversTo have lifelong protection against deadly diseases, newborns should begin receiving immunization immediately after birth. All children should be taken for routine immunization four times before their first birthday in addition to birth dose and according to the given schedule. Parents should carry the routine immunization cards with them at all times during visits to doctors, and especially during travel. Vaccines are available FREE OF COST at the nearest sub centre/anganwadi centre and at all government health facilities. A child who is suffering from minor ailments such as fever, cough, cold, diarrhoea on the day of immunization can still be immunized. It is common to observe some adverse effects following immunization such as fever or pain. These will subside in due time and should not be a cause of concern.

STEP 4: Communication Activities, Tools and Channels

They are the methods adopted combined with the tools (products) used to communicate effectively with the targeted audience. For instance, to reach out to a rural community, one may use folk theatre. Broadly all communication activities fall under the following three strategic approaches:

1. Advocacy 2. Social mobilization 3. Capacity building (Training)


63

There is some commonality between the first two. For instance, meeting community leaders to advocate about immunization benefits and seeking their support for immunization is as much an advocacy effort as it is part of community mobilization. Depending on the communication objective and the targeted key audience, either activity may need to be done. Sometimes, both will be required, supported by capacity building to develop the skills of the messenger to communicate the right messages. In all respects, it is a combination of activities carried out in an integrated manner that produce successful communication.

The basic difference between the first two approaches – advocacy and social mobilization – is given in the table below to make the differences clear.

Advocacy Social mobilization

Public relations/ administrative mobilization: For highlighting the issue of immunization on the administrative/ programme management agenda via meetings/discussions with various categories of government and community leadership, service providers, administrators, business managers; official memoranda; partnership meetings, network deliberations, taking the support of mass media (news coverage, talk shows, soap operas, celebrity spokespersons, discussion programmes, etc).

Point-of-service promotion: Emphasizing the need to make easily accessible and readily available immunization services.

Community mobilization: Education, informing, motivating community for action through use of participatory methods such as group meetings, partnership sessions, school activities, traditional media, music, song and dance, road shows, community drama, leaflets, posters, pamphlets, videos, home visits.

Interpersonal communication/counselling: Involving volunteers, schoolchildren, social development workers, other field staff, at the community level, in homes and particularly at service points, with appropriate informational literature and additional incentives, and allowing for careful listening to people's concerns and addressing them.

Sustained appropriate advertising: Communication that is massive, repetitive, intense, persistent (M-RIP) – via radio, television, newspapers and other available media – engaging people in reviewing the merits of the recommended behaviour vis-à-vis ‘cost’ of carrying it out.

Tools (Products) Tools help position the messages effectively. All IEC materials are tools, mass media materials such as TV and radio spots are tools; an influencer or a champion or a celebrity is also a tool. For guidelines to produce communication material, see next chapter.

Channels and Vehicles

There are broadly three channels of communication

1. Mass media


64

2. Mid-media, and 3. Interpersonal communication (IPC)

For effective communication, a mix of channels is advised. Each channel has vehicles which help to carry the message. For instance, within TV (a mass media), talk shows, TV spots, news reports are all different vehicles.

For guidelines on use of channels and vehicles, see PART 1 in this document.

For a list of different channels and vehicles and tools under them, see Annexure 1.1.

STEP 5: Monitoring and Evaluation Monitoring is used to measure if a communication intervention is progressing as planned, and to make changes if necessary. Evaluation is done to measure the expected outcomes (impacts) from an intervention. Therefore, at the stage of writing the objectives, one needs to identify the indicators. Indicators are evidence-based signals that help to measure the progress or achievement of a certain objective/activity.There are three types of indicators:

o Process indicators: What processes have been followed to help do the communication?

o Output indicators: In communication activities, are the outputs (such as IEC tools, mass-media products, etc) as desired?

o Outcome indicators: As a result of the efforts – process followed and outputs used – what outcomes (impacts) are we expecting (action on the part of the audience)?

See Annexure 1.3 for details on the difference between Formative Research, Monitoring and Evaluation to get further clarity on this.


65

Guidelines for development and use of existing IEC prototypesOn RI, Birth Dose, Measles, and JE A CD containing IEC prototypes designed to be used for creating demand and reducing dropouts on routine immunization under the Government of India’s Universal Immunization Programme has been distributed to all state offices. It also contains IEC prototypes on the importance of Birth Dose, Measles, and on Japanese Encephalitis (specifically to be used in JE-endemic districts of the country). Specific IEC materials have been developed for Birth Dose because most newborns miss getting this vaccine, which should be given in the first 24 hours of birth. Remembering to give the birth dose is as important for caregivers as it is for health centre staff. All IEC materials are in English and Hindi language versions and comprise the following:

Posters Hoardings Press ads

Guide on RI, with answers to frequently asked questions (FAQ) developed especially for frontline health workers. This guide also answers questions on Birth Dose, Measles, and JE.

Posters For best visibility and impact in public places, the recommended size for printing these posters is 29x38 inches. Please decide after considering available space for display, and available budget.

Ensure there is ample visibility for the posters. For real impact, ensure that large-sized posters are displayed – and remain displayed – at places where many people gather and wait for a certain amount of time, such as at waiting rooms of hospitals, bus and train stations, etc. Such settings provide better opportunity for people to retain the message they read. See a list of recommended places at the end of this annexure.

Printing Specifications

Colour: 4 colour throughoutSize: 19x29 inches (Cut to size from paper of size 20 x 30 inches) OR


66

29x38 inches (of same ratio cut from paper 30x40 inches) Paper: Chromo art paper (170 gsm will give best results for indoor display; and

displays in areas where posters can be protected from being damaged) For printing in bulk for outdoor display, use 95-100 gsm For superior quality printing to display indoors for a longer time, use 170 gsm imported art paper, matte finish; can also be laminated.

Fabrication: Cut to size Display: To be displayed at places of maximum visibility. For best impact once the

poster is displayed, the lowest edge of the poster should not be lower than stomach level (about 3 ft from the ground). This enables good readability.

Press advertisement The press ads may be released in both state-level and district-level newspapers at any given time during the year. The ads may be repeated a number of times, in different newspapers subject to availability of

resources. Both colour and black&white ads are possible. Especially in areas of low coverage of vaccination, keep the frequency of release high.

Two different size options for press ads is available:

1. Horizontal (Half-page, 200 column centimetres – 25x33 cm)

2. Vertical (Quarter page, 100 column centimetres – 25x16 cm)

Both press ad prototypes are available in English and Hindi language versions.

Press ads in the local language

Any state wishing to release the press ads in the vernacular language may do so by using the prototypes after carrying out appropriate translations.

Hoarding Specifications: Colour: 4 colour throughoutSize: 1 x 2 ratio (8x16 ft, 10ft x 20 ft, 12x24 ft, etc, depending on space/resource

availability) Medium: Can be painted on tin sheets and mounted on wooden/metal frames.

Can be printed on flex and mounted on steel frames.


67

FAQThe guide-cum-FAQ (frequently asked questions) for RI has been designed for frontline health workers. It answers the most relevant questions on RI.

There is evidence that most caregivers receive their knowledge about vaccines from health workers. The reason is based on trust. A frontline health worker who can be trusted to give the correct answers on RI, and can help answer all concerns of caregivers regarding vaccine schedule, for instance, can help in creating demand and reducing dropouts.

Note for training facilitator During the health worker training, facilitators are advised to read through the guide, word by word, along with the participants and explain to them about the contents in the guide.

Printing Specifications for FAQ booklet Colour: 4 colour throughoutOpen Size: 8.25 inches x 11.7 inches (A4 size paper); Closed Size: 8.25 inches x 5.7 inches Pages: 12 (Self cover 4+4) Paper: 210 gsm Imp art card matte; Fabrication: Cut to size and centre stapled, Aquas

coated

Additional IEC material You may innovatively use the existing IEC to produce more IEC materials given below

Sl No

New IEC Use Existing IEC

1 Bus panels(sizes may vary according to space available on the back of the bus or the sides of the bus).

Use hoarding. The ratio of length x breadth of hoarding and proposed IEC material is almost similar. Ask printer/ designer to make minor modifications if needed before developing new material.

2 Banners(sizes may vary from as small as 2ftx6ft to as large as 6ftx18 ft. Decide according to space available for display, readability, and readers).

3 Wall painting(ensure that the text given at the bottom of the poster is visible and readable from at least 20ft distance and is at least at the waist level of the reader).


68

Cost of producing banners of the following specification: Cloth rally banners

Material: Soft sheeting fabric without starch, 100% cotton

Ready size: 17”x72” exclusive of a 3” border each side to be stitched on 17” side








Cost of producing posters of the following specification: Size: 19x29”

Colour 4 colour


Quantity: 100,000


4 Handouts(also called leaflets) of size 7.4 x 11.7 inches (Size of A-4 sheet is 8.25x11.75).

a) To improve readability, increase point size of text given in semi-circle at bottom right corner that says “For more information, contact ANM or ASHA with the Mother and Child Protection Card”.

b) Use back side of same handout to print Key Messages on RI. These messagesare on the back cover of the FAQ booklet. Ask designer/printer to copy message box and increase point size to fit in the handout page. You may also use an image along with the messages.

Use press adprototype (25x16 cm or 100cc)

5 Kiosks – Printed on Flex and mounted on wooden or steel frames and displayed on electric poles. Unless printed in large size, small sized texts get smudged and affect readability.

Use poster prototype. Some of these can be expensive to produce, so depending on budget available, a limited number can be developed. (ImpNote:Display strategically for maximum visibility.)

6 Vinyl sheets for large displays on walls and to serve as backgrounds during workshops.

7 Back-lit acrylic box displays for indoors (such as in waiting rooms of hospitals/health centres) as well as outdoors (such as at bus stands, railway stations, chemist shops).


69

Guidelines to develop print material for audiences with low literacy levelsIn India, people with literacy problems will be found among most social groups, with different levels of literacy in different states and regions, and between genders. Guidelines for designing print products for low-literate stakeholders are given below:

1. Most low-literate stakeholders have:

o Tendency to think in the immediate rather than in futuristic terms. o Have a limited vocabulary. o Make literal interpretation of information. o Difficulty with complex information processing, such as tables and graphs.

2. Use short, single-syllable words, from the culture of the target group. “Vaccinate your child today!” “Vaccines save lives! (Use single-syllable words).

3. Pre-test your communication material with the target stakeholder groups.

4. Involve members from target group in development of material.

5. Messaging must contain an “ask” (an action step) such as “call for appointment” or “bring child to vaccination centre at…(time) on….(day).

6. Organize the action messages in the way you want targeted stakeholder to use them – the most important points first and last.

7. Avoid technical terms unless absolutely necessary.

8. Symbols and charts can be open to different interpretations. Avoid unless necessary. Only use universally accepted symbols such as an arrow, etc.

9. If there are multiple messages, group information separately.

10. Any picture used must be action oriented, not just be there for the sake of being there.

11. Pre-test materials for:

o Attractiveness (use of visuals, colours, text) o Comprehension (how well the message is understood, and the relationship

between text, images, colours) Cultural acceptability: Does not antagonize strong cultural beliefs, is acceptable to both genders, age groups, in the community.

NOTE: For a checklist for developing material for low-literate audiences, see Annexure 2.11.


71


73

Annexure 2.1: Communication Strategy SmartChart (adapted from Spitfire Communications)

Step 1: SITUATION ANALYSISInternal Scan: What are our strengths and challenges that may impact our communication strategy (budget, staffing skills, resources, etc.)? Strengths: Challenges:

External Scan: What external factors may impact the strategy (e.g., timing of the event, activities of others in immunization, barriers audiences may face to taking action, other potential obstacles or opportunities such as lack of support from other departments)? Strengths: Challenges:

Define our position on immunization: Do we need a communication plan that will frame, fortify and amplify, or reframe?

Frame: No one is talking about immunization.

Fortify and amplify: (The way immunization is being discussed, we need to push it further).

Reframe: We want to change the discussion about immunization.

Step 2: PROGRAMME DECISIONSBroad Programme Goal: What do we want to achieve over the long term in immunization? Objective: What’s the first measurable step we need to accomplish within the next 6 months to move toward our goal? This objective must be SMART. Decision Maker (main influencer): Who can make the objective a reality by taking a specific action or by changing a specific behaviour?

Step 3: STRATEGIC CHOICESDecisions to make Primary Audience 1 Audience 2 Audience 3 Target audience: Who must we reach to achieve our objective? (There’s room to describe three stakeholders here. We may not have that many or we may have more.)Who can most help us achieve our objective? Who can we persuade?(We must think small – segment our audience as much as possible. This is not the general public. Our audience may be our decision maker, or it may be people who can help influence our decision maker.) Readiness: Where is our audience on our issue? Are they ready for what we want to tell them? If they don’t yet know about, care about and believe in our issue, we’ll check Stage 1. If they know, care and believe – but aren’t ready to act – we’ll check Stage 2.If they’ve already taken action and are ready for the next steps, check Stage 3.

Stage 1: Sharing knowledge

Stage 2: Building will

Stage 3:Reinforcing action

Stage 1: Sharing knowledge

Stage 2: Building will

Stage 3: Reinforcing action

Stage 1:Sharing knowledge

Stage 2:Building will

Stage 3:Reinforcing action

Positioning: What existing belief or value can we tap into to engage and resonate with our audience? What existing belief might be a barrier we have to overcome? Where’s their comfort zone? Make the issue personally relevant for them. For example, “elders blessing children for long life” is a universal Indian value. This positioning was used in the IEC prototypes developed by the GOI to come up with the key line “The right vaccine at the right time, blessings for a healthy life.”

Value: Barrier:

Value: Barrier:

Value: Barrier:


74

Message: What key points do we want to make with each target audience? Make sure messages:

Are based on the audience’s core concerns;

Overcomes their barrier; Have an ask that is in their comfort zone

(or offers a benefit that outweighs the risk);

Emphasize reward and convey hope toward success, if possible

Tap Value: Overcome the barrier: Ask: Echo Vision:

Tap Value: Overcome the barrier Ask: Echo Vision:

Tap Value: Overcome the barrier Ask: Echo Vision:

Messengers: Who will best connect with our audience? Is it the ASHA, ANM, a local leader, a celebrity? Someone who is their social reference group? Can we show them a trusted leader taking action? People listen to people, not institutions. Make sure the messenger is credible. The right message delivered by the wrong messenger may fall on deaf ears.

STEP 4: COMMUNICATION ACTIVITIESTactics: What activities will we use to deliver our messages to our target audience(s) (e.g., meetings, web sites, newsletters, press events, letters, phone calls, paid advertising)?

Timeline: When will we implement each tactic? Note key dates, deadlines and events. Be realistic – we can’t communicate audiences 24/7. Plan ahead for the unexpected – sometimes events beyond our control can be a chance to connect with our audience. Use a timeline to plot out all steps that go into each tactic listed.

Assignments: Who will implement each activity noted in the timeline?

Budget: How much time and money will we spend on each activity? Be realistic about what we can accomplish given available resources.

Audience 1: Activities:Audience 2: Activities: Audience 3: Activities:

STEP 5: MONITORING AND EVALUATIONOutputs: What will we produce to reach our objective (e.g., emails sent, events planned, phone calls made)?

Outcomes: What is the result of our outputs that demonstrates incremental progress toward our objective

STEP 6: FINAL REALITY CHECKBefore we put our strategy into action, test following questions to see all needs are fulfilled:

Is the strategy achievable?

Are resources available for our strategy? Do internal and external factors support the decisions made?

Is the audience carefully identified? Are we motivating the right people to take the right action at the right time?

Will the activities move us toward our objective? Will they reach the appropriate audience(s)?

Are the best persuasion practices being used, such as respecting the audience’s cultural needs, sharing hope, making them the hero, positioning the issue within the social norms, etc.?

Are there any assumptions or guesses built into the plan that require further research to confirm or correct?

Is there buy-in from Programme Mangers to implement the plan?

Are there other objectives beyond these that we need to ensure we’re taking to meet our overall goals?

Can we measure the progress? If we answered no to any of these questions, we must go back and work through our choices again.


75

Annexure 2.2: Desired behavioursDesired behaviours in service providers Desired behaviours in the caregivers Policymakers in the Health Department (especially Immunization)

Increase funding and provide programme support for RI (and for campaigns).Support to ensure synergy between immunization and any piggybacked interventions during campaigns. Actively participate in advocacy efforts for immunization with policy makers from other departments. Ensure that the right messages about routine immunizations are reinforced during campaigns.

Health Workers (ANM/AWW/ASHA/Male Health Worker) The ideal health worker communication practices (with caregivers) should be to:

Emphasize the importance of vaccination. Fill out the vaccination card and explain what is being written. Explain to caregiver where and when to return for next immunization, and how many shots remain. Explain common side effects and what to do about them. Respond to doubts and fears in a reassuring manner. Respond to questions clearly, in a simple, easy to understand language. Inspire the parent/caregiver by congratulating for completion of immunization of the child. During a campaign, explain that the routine vaccinations are still necessary at the health facility or outreach site.

Caregivers Complete the series of routine vaccinations (visits beginning at birth or as specified on the child’s immunization card). During any supplemental campaigns, take a child of the recommended age to a vaccination post (or assure the child is at home during a house-to-house campaign). Treat side effects as recommended quickly. Take the child’s immunization card whenever visiting an immunization outreach site or health center.

Communities Work with health staff to plan convenient times and locations for vaccinations. Promote benefits of immunization in communities. Provide logistical support (help with transport or supplies for the cold chain). Help mobilize families and help track down the hard-to-reach people or dropouts.

Annexure 2.3: Key behavioural barriers

Key behavioural barriers identified in caregivers (Source: Pop Council study; Policy Brief No 8, 2010; Increasing complete immunization in rural UP)

Low risk perception of disease. Lack of faith in vaccination. Lack of vaccine related knowledge. Fear of side effects of vaccination. Lack of knowledge of the place and day of immunization. Uncertainty of service provision. Limited counselling by health workers.

Behaviour facilitating factors A number of things can help parents/caregivers feel motivated to demand immunization for their children. Some of the most essential are listed below: Knowledge of the next scheduled immunization day. Awareness of the risk if child is not fully immunized. Credibility of frontline health workers as a source of information. Knowledge of side effects of vaccination. Ensured availability of friendly health providers and supplies. Women’s education.


76

Annexure 2.4: Quantitative data on caregivers’ behaviours and practices regarding immunizationThe Coverage Evaluation Survey of 2008-2009 (CES 2009) provides significant information on the knowledge and attitude of caregivers and health workers towards immunization.

Table 1: Findings from CES on knowledge and behavior practices in Immunization Sl No

Knowledge and Behavior

Findings (what percentage)

1 Full vaccination Proportion of children age 12-23 months receiving full immunization: 61% [Urban areas: 67.4%; rural: 58.5%] About 8% no vaccine at all

State coverage vs national average

Lowest immunization coverage: Arunachal Pradesh (25%) Highest immunization coverage: Goa (88%)

2 Awareness about the four (BCG, OPV, DPT, Measles) vaccines

58.1% mothers knew about all 4 vaccines to be given to child in first year of life Awareness higher in mothers from urban areas: 68.1%; In rural areas: 54.3% 12.2% mothers could not recall any one vaccine

3 Main source of information about immunization

From AWW: 38.2%; From ANM/LHV/Male Health worker: 38% ANM/LHV/Male health workers were the main source in AP, Goa, HP, Tamil Nadu, Mizoram, Uttarakhand, West Bengal, and UP. AWW in Bihar, Chhattisgarh, Gujarat, Jharkhand, MP, Maharashtra, Orissa, and Raj Government doctor (24.7%). In states like J&K, Meghalaya, Tripura, government doctors gave info to more than 50% mothers Family member (21.3%)

4 When asked about the reasons for not receiving the immunization card

56.5% of mothers reported they were not aware of immunization card 22.6% said that the card was not available at the health facility More educated and economically better mothers saved immunization cards (24% in Raj; 79% in Kerala)

5 Literacy 76.6% of children of mothers who had completed at least class 10, immunized Only 45.3% of the children of illiterate mothers were fully immunized

6 Social Scheduled tribe children (49.8%) fully immunized Scheduled castes (58.9%) OBC (60.6%) other classes (66.3 %)

7 Economic Only 47.3% of children from the lowest wealth quintile were fully immunized 75.5% children immunized from households with highest wealth quintile

9 Distance travelled for immunization

44% mothers travelled less than 1 km 39% travelled 1-3 km 17% travelled over 3 km Average: 2.2 km

10 Main reasons for revisit to health facility/vaccination center

Only 5% mothers revisited. Of these: o 45% revisited for non-availability of vaccine at the health facility o 27% because of absence of the provider in the first visit; o 26% for long waiting time


77

Annexure 2.5: Qualitative information on behavioursFindings from an extensive study of grey literature on immunization in India (a review of 17

projects/programmes) illustrate how certain behaviors and practices, both by health workers and by caregivers, have impacted immunization coverage and led to low demand and increased dropouts. See table below for a list of factors in order of priority (detailed explanation on some of the major factors follow the table at Annexure 1.6).

Factors associated with non-immunization in India (in order of priority) (the figures against each is the number of studies where these factors were found)Caregivers Related System/Service Related

Parental practical knowledge (not knowing child’s age, when need to go, where, hours of operation, who, remembering) – 9 Conflicting priorities – too busy earning money, with family or social obligations, caring for older children, mother is sick, summer travel (when women usually visit their parents’ house, etc) or mother sick - 6 False contraindications (particularly sick children, baby too old, and baby underweight) as factor for health workers &/or parents – 6 Fear of side effects – 6 Religious/cultural/social beliefs/norms and rumor (sterilization, HIV), influences, e.g. problem accepting male vaccinators (mothers spend the initial period after the birth at parents’ home), misinformation about payment for immunization services – 5 Perception of importance of vaccination for my child’s health/attitude that better to treat illness (attitude towards curative and preventive aspects of health care) (Misconception about child growing well and the need for vaccination) – 3 Scientific knowledge (how vaccination acts) – 3 Income/socioeconomic status – 3 Recent migrants/seasonal migration – 3 Lack of interest/Level of motivation/lazy (mainly parents) - 3 Residence - urban children more likely to be fully vaccinated - 2 Gender - 2 Perceived efficacy of vaccine - 2 Mother's education - 1 Birth Order - 1 Fear of being embarrassed, harassed, humiliated, associating with male health worker - 1 Familiarity and/or use of other health care services - 1 Exposure to mass media - 1 Households with female headship - 1 Mother's employment - 1 Religion - 1 Mother's age - 1 Antenatal care during pregnancy – 1 Mistrust of health staff - 1 Perception that child is too sick, “weak” for vaccination/fatalism - 1 Autonomy of women/father or mother-in-law pressuring against/husband refusal - 1 Family size - 1 Demand/acceptability of vaccination - 1 Residence in un-recognized geographical location/slum – 1 Perceived safety of vaccine/fear of multiple doses/ vaccination - 1

Lack of resources/logistics funding)/stock outs that affects reliability, cold chain etc. – 7 Distance/travel conditions, access – 5 Reliability (no cancellation of sessions) (both fixed and outreach sessions) – provider absent, lack of supplies, fuel; other priorities – 4 Health staff’s motivation, performance/competence and attitude/+ knowledge + behavior +ability to communicate with mothers (when to return, which vaccine and how many doses are needed) – 4 Lack of promotion/follow-up of routine immunization/health communication –3 Appropriateness of time/limited day/hours when vaccination available; includes sessions that begin late and end early – 3 Waiting time – 3 Informal, illegal charges, indirect costs such as transportation – 2 Immunization refused because the child was sick - 1 Security (health workers/parents) - 1 Poor/ineffective communication regarding vaccines and benefits of vaccinations - 1 Cost and costing policies/official fees (clinics/health centers depending on client for use of curative services and when there are less clients using these services the clinics are facing problems) - 1 Use of all opportunities - 1 Use of all opportunities -contraindication, fear of giving multiple, for no clear reason - 1 Use of all opportunities - stock outs of essential vaccine or supplies – 1 Community involvement in planning and managing services in social mobilization/channeling – 1


78

Annexure 2.6: Factors associated with non-immunization

Caregivers related behaviors Parental practical knowledge: Not knowing child’s age, when to go for vaccination, where, hours of operation, who to meet, and remembering immunization were quoted major reasons for non-immunization.

Income/socioeconomic status: Poor urban children were 10 times more likely to have no immunizations than the richest children; and poor rural children were less likely to be fully immunized and more likely to have no immunizations than the children from the richest households.

Parents’ perception of importance of vaccination for child’s health: Parents got children treated only when children were ill; strongly believing that it is destiny (and God) that decided if the child will stay healthy.

Lost or forgotten health cards: When some mothers lost the immunization/health cards, or the card got damaged, they were scared to go back to the health centers for fear of being scolded by the health staff, made to pay for a new card, and/or asked to return home to retrieve the forgotten card.

Previous positive or negative experience with health services: Stories on bad behavior spread quickly. The need to associate with male health worker, and the fear of being embarrassed and humiliated were also given as reasons for not returning for immunization.

Mothers may feel it is socially unacceptable to appear in public with a sick or weak child. Such feelings are often reinforced when health workers publicly humiliate poor mothers.

Recent migrants/seasonal migrants: New urban migrants need to earn cash, so preventive services such as immunization are not a priority. Seasonal migrants are also likely to have under-vaccinated children.

Fear of side effects: Side effects can become a larger issue because fathers or mothers-in-law become very upset and refuse to allow the mother to take the child for more vaccinations.

Conflicting priorities: Earning money or growing food to be able to provide food for the entire family at the end of the day is a priority. There are also family and social obligations to keep.

Distance/travel conditions/access: Although difficult access clearly is a key barrier to vaccination in many, especially in rural settings, this factor (as others) does not always affect families equally.

Religious/cultural/social beliefs/norms and rumors: Many people wrongly believe that health staff promoted vaccination to meet their targets and please their supervisors, not for children’s benefit. The rumor about vaccination being used to sterilize was rife in the past and created permanent fear in the minds of many.

System related reasons Health staff’s motivation, performance/ competence and attitudes: Health workers are a major source of information. Bad attitude and behavior demonstrated by health staff discouraged caregivers from coming back for immunization. Some caregivers have reported being made to pay even for free services.

Service reliability/lack of resources/logistics: Health worker’s absence from duty, frequent cancellation or postponement of outreach sessions, shortage of vaccine or supplies or even occasional stock outs because of inefficient cold chain management. This is especially difficult for parents who have to travel long distances to access health services, or who may have to take leave from their work (thus losing their day’s wages).

Distance/travel conditions, access: Long distances between session sites and caregivers’ residence is a discouraging factor. Besides reasons of accessibility and safety and security, there were issues related to reliability of services.

Appropriateness of time/limited day/hours (including sessions that begin late and end early): Even on days when vaccination is offered, health staff commonly start vaccination sessions late (because they arrive late, take time to set up for vaccination, or wait until enough mothers have gathered.)

Waiting time: Mothers (in some states) feel they have to wait too long.


79

Lack of promotion of immunization services: Parents have suggested lack of promotion or follow-up as a reason for not getting their children immunized. Far too many parents leave sessions without knowing important information about return visits, side effects, etc. Ability of health workers to communicate with parents (when to return, which vaccine and how many doses are needed, etc) have been ineffective.

False contraindications: Health staff frequently refused to immunize a sick child, if they found child was weak, looked malnourished, and vulnerable.

Community involvement in planning and managing services: Communities have not been involved in planning and managing of sessions, as a result of which attendance of caregivers on session days or during village health and nutrition days (VHNDs) has been poor. In hard-to-reach areas, or conflict regions, security of health workers and parents has been a reason for dropouts. This could have been minimized with active community engagement.

Why some health workers are uncooperative Health professionals appear to expect mothers to be responsible for keeping their children healthy, which means not missing appointments and not forgetting their or their child’s vaccination record. Some health workers view mothers’ coming late for a return date or forgetting the child’s card as irresponsible behavior which justifies yelling and or otherwise humiliating the mother. Health staff themselves may feel unsupported by the health system (not given sufficient resources, supervision, training; not paid well or on time, not given incentives for routine immunization work), which may increase their tendency to treat mothers the same way.

Annexure 2.7: Reasons for dropouts and leftouts

Why there are dropouts Dropout problems may involve access issues but are usually an indication something else is going wrong. These are families who were motivated and successful in starting the series. What happened? Some reasons for dropouts would be:

o Combined with the frustration of long queues, late openings, or even cancelled services on announced days, any ill-treatment by health worker can discourage return visits.

o Poor vaccination techniques can also cause anxiety in parents. o If parents are not explained & reassured about possible reactions such as fever, then they may drop out. o If parents can’t read, all the more reason that health workers counsel them properly. Many

health workers do not fill out immunization cards, either because they’re too busy or because they think parents can’t read them.

Why there are leftouts Leftout problems involve access issues, both geographical and social. Inaccessible terrain, mountainous areas, or areas divided by natural barriers such as flooded streams. Migrant labourers and frequently shifting nomadic populations. Scattered populations based in locations far away from densely populated habitations such as at brick-kilns and mining communities. Socially secluded communities based on caste or class. Improper tracking system.


80

Annexure 2.8: Reasons for low immunization in urban areasStruggles of urban living: For the poor, especially, urban life can be hard, leaving little time to look after one’s own needs. When one is not working, one may be standing in long queues for the daily water in the mornings and evenings. Travel between home and the place of work itself takes away long hours. In the table below, the main factors associated with non-immunization in urban areas are mentioned. The source for the data is “Epidemiology of the Unimmunized Child: Findings from the Grey Literature” (Prepared for the WHO, October 2009, IMMUNIZATIONbasics Project)

Reasons for low immunization in urban areas

Factors % of urban projects % of other projects CommentsCAREGIVER RELATED Fear side effects 60.0% 30.4% Appears much more important in

urban areas Practical knowledge 50.0% 41.07% Conflicting priorities 45.0% 29.06% More urban mothers are busy

earning money Perceived importance 25.0% 21.7%

Beliefs, rumours 20.0% 32.2% Appears to be smaller factor in urban areas, perhaps because of higher education, more information

Perceived efficacy 15.0% 20.9% Acceptability 15.0% 10.4% Child too sick, weak 15.0% 8.7% Traditional beliefs may persist

more in rural areas Lost/unavailable cards 15.0% 13.0% Women’s autonomy 15.0 10.0 Safety fears 10.0 9.6 Low motivation 10.0 14.8 SYSTEM RELATED Health staff performance 35.0% 36.5% Appropriateness of time/days 35.0% 20.0% Urban mothers may have less

time flexibility. Lack of vaccine/ supplies 30.0% 36.5% False contraindications 30.0% 35.7% Missed opportunities 30.0% 27.0% More common in urban areas,

perhaps because staff assume it is easy for people to return.

Service reliability 25.0% 25.2% Distance/ access 20.0% 39.1% As expected, access is less of a

barrier in urban areas. Waiting time 20.0% 21.7% Informal charges 20.0% 14.8% Appears more common in urban

areas, perhaps because cities are more a money economy.


81

Annexure 2.9: Behave Framework

BEHAVE Framework

Target Audience

Who?A specific target audience

What?Take a specific action

Benefits & BarriersBenefits and barriers that influence the action

ActivitiesSelected program activities that address these benefits and barriers

#1. Know exactly who your audience is and look at everything from their point of view.

#2. Your Bottom Line: Whenall is said and done, the audience’s action is what counts.

#3. If it benefits them, they’ll take an action. Barriers keep them from acting.

#4. All your activities should maximize the benefits and minimize the barriers that matter to the target audience.

In order to help: To: We will focus on: Through:

Action Benefits & Barriers Activities


82

Annexure 2.10: Creative Brief Format

THE CREATIVE BRIEFBackground and Context for this piece of communication: To motivate rural mothers of children in the age group of 0-1 year to value the need for vaccination and take their children for complete immunisation. Explain specifically the key audience: Key audience: Mothers with children in the age group of 0-1.

The SMART Objective(s) – Results of this piece of Communication (Stated in measurable behavioural terms) The percentage of mothers of children of 0-1 year demonstrating a positive attitude to vaccination that it can prevent their children from vaccine preventable diseases increased from 50 to 70 by Dec 2012What key benefit(s) will be emphasised? (This must be evidence-based from research studies)

1. Complete immunisation protects children from a number of life-threatening diseases. 2. A healthy child will be a happy child. 3. Vaccination is available free of cost

What action will people be asked to take? 1. Bring children to the vaccination site, come back 5 times in a year and ensure completion of

immunisation. 2. Maintain RI card.

Which psycho-social considerations, i.e. tone, symbols, colours, etc and approaches is recommended? Friendly, rewarding, building self-efficacy/control tone For development of posters:

1. Use lively (live) pictures of mother, child 2. Demonstrate love for the child 3. Convey parental responsibility 4. Convey social recognition

Any other creative considerations, if relevant and necessary Child-centric approach, using symbolism to indicate the five contacts in a year. Brand it with a memorable theme, eg the “power of five” as a symbolic approach. Convey self-efficacy.How will this be monitored and evaluated?

1. Pre-test a draft prototype before implementation 2. Check ANM registers 3. Document poster display at selected sites 4. Recall of key messages through random surveys.

Proposed activities Service providers and mother contacts, both at onsite institutional and community level through group meetings will be held. Timeline and estimated budget: A pragmatic timeline (if the process is thoroughly followed) is 30-60 days from the development of the creative brief and assigning the task. Budgets will usually be proposed by the creative agency. Negotiations are always possible, but real creativity costs money. A creative design agency can charge anything between Rs 25,000-50,000 for the development of a concept and design for one single quality poster. Get printing quotes from agencies to get the full cost of production. Contact information: Client: Agency Prepared by: Programme MangerApproved by: Client: Date: Agency: Date:


83

Annexure 2.11: Checklist for production of material for audiences with low literacy levelsVisual appeal Content and style 1. Audience interprets the visual easily

2. Audience finds relevance of visual to text

3. Colours if used are appealing

4. Visuals are in the appropriate size and position

5. Cues have been used to draw attention to key information

6. Good balance of white space and other visual and text elements

7. Familiar to the cultural context

8. Meets the criteria of one visual one message norm

9. Audience can tell which presentation style (box, arrows, underlining, etc) they find most appealing

10. Headline texts are simple and close to text they refer to.

11. Text is written in sentence case (lower case as people are used to reading that more).

12. The point size is appropriate to the type of print publication (Text: minimum 12 pt, PPTs: 24 pt; poster headings (80-100 pt); poster text 40 pt.

1. Audience can identify the language as their own

2. Words are familiar to the reader.

3. Highly technical or a new word is explained clearly

4. Words are mostly single-syllable

5. Sentences are simple, specific, and written in the active voice.

6. Real life examples are given rather than abstract concepts

7. The sequence of ideas is logical

8. Material encourages engagement from audience.

9. Action point is clearly established, and audience understands what to do.

10. Action point is not difficult for audience to practice.


85

References(In alphabetical order)

1. A Field Guide to Designing a Health Communication Strategy: A Resource for Health Communication Professionals. JHUCCP

2. “A new look at an old problem: Why do so many poor children miss out on essential immunizations?” Abhijit Banerjee and Esther Duflo; UNICEF Policy Paper; Child Poverty Insights; June 2011

3. “Assessment of IEC activities of Govt Health Centres and ICDS Anganwadis: Towards reduction of under-nutrition in Gujarat.” Netna, Govt of Gujarat

4. Baseline Situation Analysis: Immunization and Antenatal Services. Factsheets. USAID-MCHIP (Dist Banda, UP; DistDeoghar, Jharkhand; DistGonda, UP; Dist Varanasi, UP; DistJamtara, Jharkhand.

5. Behaviour change perspectives and communication guidelines on six child survival interventions. Renata Seidel; UNICEF, AED and JHUCCP; Dec 2005

6. Chalo Baat Samjhey aur Samjhaayen (in Hindi) (Facilitator guide and training manual in IPC for Health and ICDS Workers); UNICEF and Government of Uttar Pradesh, 2010.

7. Communication Capacity Building for Health and ICDS Functionaries in 3 districts of Uttar Pradesh-Inception Report. UNICEF; 2010

8. “Communication for empowerment: Strengthening partnerships for community health and development.” Judi Aubel; Working Paper Series; UNICEF; 2001

9. Communication for immunization campaigns for maternal and neonatal tetanus elimination: a guide to mobilizing demand and increasing coverage. Malia K. Boggs, Paul M. Bradley III, Charlotte Z. Storti; UNICEF, Save the Children

10. Communication for Immunization Programmes. Mid-level management course for EPI managers. Module 3. WHO

11. Communication for Polio Eradication and Routine Immunization: Checklists and Easy Reference Guides. WHO, UNICEF, and USAID

12. Communication framework for pneumonia and diarrhea control. UNICEF

13. Coverage Evaluation Survey. UNICEF; 2010

14. Epidemiology of the Unimmunized child: Findings from grey literature. Immunization Basics Project, Oct 2009

15. “Evaluation of innovative approaches to improve coverage in India. Assessment of RED in Assam.” (Powerpoint Presentation)

16. “Increasing complete immunization in rural Uttar Pradesh: Implications for Behaviour Change communication.” Policy Brief No 8, 2010, Pop Council

17. “Making Behaviour Change communication effective–Experiences.” Consolidated Reply, Solution Exchange; MCH Community, Compiled by Joy Elamon and Meenakshi Aggarwal, March 2011

18. “Measuring the Impact of Communication in Public Health Programs.” D. Lawrence Kincaid; JHUCCP; 2005 (Powerpoint Presentation at the Communication Initiative Partner’s meeting, IADB, Dec 2005)

19. “Mobilizing for Action: Communication-for-Behavioural-Impact (COMBI).” WHO working paper.

20. Performance assessment of Health Workers Training in Routine Immunization in India. WHO-NIHFW Collaborative study; NIHFW; Dec 2009

21. Promotion of Immunization in Uganda: Booklet for Leaders. Uganda Ministry of Health, UNICEF, WHO, USAID; 2002

22. “Providing monovalent and oral polio vaccine type I to newborns: findings from a pilot birth-dose project in Moradabad district;” Bulletin of World Health Organization 2009; 87:955-959

23. Strategic communication for behavior and social change in South Asia. UNICEF Regional Office for South Asia; 2005


86

24. “Perseverance Helps: Breaking the ice; Involving local community in it.” Success story; USAID/MCHIP paper.

25. “Sustaining EPI: What can communication do?” Mark Rasmuson. HEALTHCOM Project (Originally prepared for The 1990 Global Advisory Group Meeting of the WHO Expanded Programme on Immunization (Cairo, Egypt); October 1990

26. “Talking with parents about vaccines for infants.” Information for Providers (Handout). American Academy of Paediatrics, CDC, American Academy of Family Physicians, Department of Health and Human Services, USA

27. “Understanding Immunization and Vitamin A Communication In Rural Cambodia: A formative research study.” Siem Reap, Cambodia; USAID and American Red Cross, Cambodian Red Cross, Ministry of Health, Cambodia; July 2006

28. Vaccine Delivery Innovation Initiative: Project Summary. Bill and Melinda Gates Foundation, Bihar, 2009-10

29. Why invest in communication for immunization: Evidence and Lessons Learned. Silvio Waisbord and Heidi J. Larson; UNICEF, Health Communication Partnership (USAID) and PATH; 2005

30. “Widening the coverage of immunization programme. Women and Child Health at Scale.” Working paper series 7, Rachna Program 2001-2006. CARE

31. “Women and Child Health at Scale.” Rachna Program, 2001-2006, Working paper Series, No7, CARE

part1: operational guideline

Documents