Interpersonal Communication for Immunization: Training for Front Line Workers - Facilitator Guide and Participant Manual

"Research in ECA [Europe and Central Asia] has shown that health workers do not always engage with caregivers in an open and supportive way, often using a patronizing and top-down approach in communication."

As a result of time constraints and limited communication capacities, health providers can fall short in understanding the immunisation-related concerns, fears, and expectations of caregivers and fail to identify and address vaccine hesitancy. To help strengthen the communication and community engagement skills of front line workers (FLWs), the United Nations Children's Fund (UNICEF) Regional Office for Europe and Central Asia (ECARO), the Johns Hopkins Center for Communication Programs, and UNICEF Country Office staff in Bosnia and Herzegovina and Serbia developed this interactive and evidence-based training package, which consists of a Facilitator Guide and a Participant Manual. Bringing in the perspectives of ECA countries, the resources build on the global Interpersonal Communication for Immunization (IPC/I) package (see Related Summaries, below).

While immunisation coverage remains high overall in the UNICEF ECA region, several countries in the region have registered a decline in immunisation in the general population, and there are very low immunisation rates in marginalised groups, including the Roma. A 2017 regional assessment led by the UNICEF ECA Regional Office found that several of the key determinants leading to vaccine hesitancy were linked to the quality of communication and interaction between caregivers and health professionals.

Thus, UNICEF contends that FLWs are critical influences on caregivers' immunisation behaviour; building trusted relationships with caregivers and community members can increase the likelihood that children will receive recommended vaccines on time. To that end, the training package is meant to help FLWs identify and address their own biases and misconceptions and to equip them with the essential knowledge, skills, and attitudes they need for positive and meaningful IPC in the context of immunisation. Specific objectives of the 3-day group training outlined in the package are to help FLWs:

• Understand and apply the key principles on communicating with caregivers;
• Learn and practice skills to listen and engage in conversations aimed at increasing uptake of vaccines;
• Improve confidence and ability to effectively respond to caregivers' needs and concerns regarding vaccine safety and effectiveness, based on evidence; and
• Increase use of dialogue-based communication to increase immunisation rates.

The Facilitator Guide features a scripted approach that is meant to decrease lecturing and increase participation. The idea is to give participants the chance to share their knowledge and experiences and to engage in applying their new skills and concepts in real-life scenarios. Detailed guidance and instruction is provided for 8 individual modules, each of which is comprised of a number of sessions that address specific content through learning activities and discussion:

1. Introduction and overview
2. Immunization technical review
3. Understanding behaviour and barriers
4. Active listening to understand your caregiver
5. Communication during immunization
6. Communication in depth
7. IPC in communities
8. Review, next steps and closing

The companion Participant Manual is designed to serve as a workbook for use during group trainings and as a resource for continued self-study. It seeks to help FLWs identify ways to maximise the limited time they often have to spend with caregivers. It walks FLWs through strategies to help overcome barriers to routine immunisation, despite the real and perceived limits of control FLWs have over elements of their work. The resource addresses the following topics:

• Principles of communication
• Respect and equity
• Gender and power dynamics
• Empathy
• Active listening skills
• Provision of information in a way the caregiver can understand
• Childhood vaccines and the diseases they prevent
• How to discuss and address common vaccine fears
• Group facilitation
• Identifying and engaging with key community influencers
• Problem-solving
• General persuasion skills

The intention of the Participant Manual is to not only to advise FLWs on what to do, but also on how to do it. A number of strategies, exercises, role-plays, algorithms, scenarios, examples, and tips are included to support the application of knowledge.

Materials and examples in the training package have been tailored to the specific contexts of Bosnia and Herzegovina and Serbia. However, the fundamental concepts, skills, and approaches introduced and used in this package apply broadly across the ECA region and can be adapted and applied in other regions worldwide. Review and adaptation of the package is recommended to maximise its relevance and accessibility for local contexts, immunisation priorities, and the needs of both health workers and caregivers. For guidance on adaptation, see "Training package adaptation and use", beginning on page 15 of the Faciliator Guide, as well as Annex A in that same document.