Strengthening Immunization Programs: The Communication Component

"Advocacy, social mobilization, and program communication should be an inherent part of immunization programs."

This report provides an overview of immunisation communication and describes how to maximise its contribution to immunisation programmes in developing countries. The discussion and examples are based on lessons learned from behaviour-centered analyses and programming, including a detailed case study of Madagascar's immunisation communication activities. Examples of communication activities include advocating to make immunisation a priority of decision-makers, mobilising communities to participate in immunisation services, and educating caregivers about the importance of immunisation (thereby influencing them to have themselves and their children completely vaccinated according to schedule). However, as author Lora Shimp explains, various barriers and challenges (e.g., lack of community involvement in programme planning and service utilisation, lack of information provided to intended audiences explaining the benefits of immunisation) can impede the effective implementation of the communication component within immunisation programmes.

Here is where partner coordination comes into play, according to Shimp. For example, a sub-group specific to supporting immunisation communication has grown out of the regional Task Force for Immunization (TFI), an 11-year partnership of various organisations working together to shape and guide immunisation support for Africa. The discussions during and recommendations that emerge from annual communication meetings are shared with immunisation technical experts through TFI, the Polio Consultative Group of Experts, the Global Alliance for Vaccines and Immunization (GAVI), and Expanded Program on Immunization (EPI) Managers' meetings in order to influence global, regional, and national immunisation agendas and programmes. In general, key activities for a global or regional communication partnership to support immunisation include: establishment and implementation of a comprehensive advocacy, information, and communication strategy; provision of communication technical support; strengthening of coordination among international organisations and partner agencies; and documentation, sharing, and dissemination of country and inter-regional advocacy and communication experiences, lessons learned, tools, and activities.

At the national level, Shimp stresses the importance of engaging a variety of actors in programme planning, implementation, and monitoring. These actors include: political authorities, local and traditional leaders, religious leaders and institutions, women's groups and other community groups or associations, school-affiliated programmes (e.g., clubs, scouts), local media (e.g., radio stations, television broadcasters, journalists), health providers (e.g., doctors, nurses, midwives, traditional and private practitioners), and individuals in the community who are dynamic and who can serve as animators and mobilisers. A text box describes the role of Inter-agency Coordinating Committees (ICCs) in countries such as the Democratic Republic of Congo (DR Congo), where the ICC for immunidation, led by the Ministry of Health (MOH), was formed in 1996 to harmonise approaches and support for polio eradication. One key approach was the "matinée scientifique" (technical meeting of experts, officials, and media) to share technical expertise on a particular health topic and to advocate for governmental policy and societal behaviour change for child survival.

Shimp next explores the fundamentals of immunisation communication for national EPI programmes, noting that effective immunisation communication requires integration of communication activities into EPI planning, structural support, management and technical inputs, and community involvement. Shimp outlines communication programme management instruments and inputs, noting that the strategy should be based on formative research and behaviour change communication (BCC) analysis as well as on immunisation assessment findings and recommendations.

A text box includes discussion of communication indicators, with a number of questions divided into different categories designed to help guide the evaluator. Noting that, because a priority of EPI is to improve demand and utilisation of services, Shimp provides a figure to illustrate suggested inputs, communication outputs, and outcomes that could result, as well as their link to immunisation indicators to be able to demonstrate immunisation and public health impact. Shimp also notes that "Consulting with the community and using participatory planning techniques will engage key local partners in the program from the beginning....The assessment should elucidate communication issues relevant to the proposed intervention, particularly local means of information dissemination, persuasion, and social exchange, all of which are important socio-cultural issues." An example from Uganda illustrates how improved communication between communities and health staff can be beneficial in building community awareness and more effectively engaging communities in planning and implementation of services. In this text box, results in terms of immunisation coverage and lessons learned are outlined.

"How do the various immunization communication issues, inputs, and strategies outlined in this document come together into a comprehensive approach within the immunization program? A case study from Madagascar (Annex) is included to provide an illustrative example that can be referenced and adapted for immunization communication programs and activities in other countries." Lessons learned from this experience include:

• "Crucial role of an entirely mobilized community (including political leaders, traditional leaders, community groups, health staff, and volunteer mobilizers) in achieving clear objectives for an integrated public health program. The involvement of authorities was important early in the process, not only to garner their support for reinvigoration of EPI and polio eradication, but also to motivate health staff and promote community participation.
• Success of community approaches that utilize existing networks and focus on key indicators and messages. Indicators and messages may include completion of the vaccination schedule before 12 months of age and tracking of newborns and defaulters, Champion Community and child-to-child initiatives, use of child health cards with parents, and use of child tracking cards and a tracking system with the health center.
• Constant focus on monitoring of community agents and ensuring communication and collaboration with health centers...
• Importance of reinforcing IEC [information, education, and communication] activities and having standardized materials that can be adapted to the realities of each region....For example, child health cards should be used by parents and health facilities, and diplomas should be used to track the completed vaccination schedule and as a motivational tool.
• Promotion of 'small, do-able' actions and messages that support and reinforce these actions...[such as] awareness-building activities with religious and community leaders on the AFP [acute flaccid paralysis] case definition, as well as the need to monitor polio eradication indicators.
• Use of mixed media and mixed channel approach....In addition to advocacy and interpersonal communication channels, the local media - particularly local radio stations - have been important partners. Radio stations broadcast health messages and aired radio spots each month (four to five spots each day) on increasing vaccination coverage (including completion of vaccination and awarding of diplomas before one year of age) and 'bonus' spots on AFP detection..."