Communication for Routine Immunisation and Polio Eradication: A Synopsis of Five Sub-Saharan Country Case Studies

In October and November 1999, a series of case studies were carried out in five sub-Saharan countries. The broad objectives were to: document communication activities for polio eradication, routine immunisation and surveillance; exchange effective and innovative experiences; and provide recommendations for the improvement of communication interventions. The initiative was a collaborative effort undertaken by the Ministries of Health of visited countries, the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the Unites States Agency for International Development (USAID) and its subcontractors (BASICS, CHANGE and JHU-PCS). Visited countries were the Democratic Republic of the Congo (DRC), Mali, Mozambique, Nigeria and Zambia.

Recommendations

1. Improve the availability of reliable immunisation coverage data:
   Reliable immunisation coverage data on which to measure the success of NIDs (National Immunisation Days) and routine immunisation were not always available in the visited countries. It was therefore difficult to measure the true coverage of NIDs or routine immunisation.
   
   

   In order to improve coverage data, the studies suggest a number of alternative actions:

   • Adjust denominator figures to realistic levels on the provincial and/or district level for estimating coverage.
   • Conduct national and/or provincial coverage surveys.
   • If NIDs coverage is over 100 per cent and possible counting of children over 59 months of age has been ruled out, consider using this revised coverage figure as the denominator for future coverage.
2. Strengthen health education:
   Although social mobilisation has been very successful in mobilizing the majority of the populations to attend the NIDs, more effort should be geared towards providing basic health education to caretakers. Such education could be an investment in the improvement of their knowledge and attitudes towards immunisation. Although information is seldom enough for people to change behaviour, improved knowledge and understanding as well as supportive attitudes towards immunisation by secondary audiences/influencers, could positively increase and sustain the long-term demand for EPI services.
   
   

   Health education activities do not have to be costly and can be grafted onto what already exists. However, they need to be strategically designed and appropriate to their audiences. Suggested activities include:

   • Use of face-to-face communication at each immunisation point: With this perspective, vaccination teams should be trained in information, education and communication (IEC) skills and particularly interpersonal communication, to improve demand and acceptance of immunisation services by the populations. For example, a short list of three to four key points could be provided to the vaccinator and the person who checks each immunised child. The information could be provided to three or four mothers/caretakers at a time. In addition, mass media and/or traditional media could be used while mothers and children are waiting for immunizations.
   • Involve non-health professionals to provide health education: Besides NIDs, health education should be provided routinely through a variety of channels. Channels could include schools, religious gatherings, traditional media such as drama and songs, women's groups and youth groups. In Mali, for instance, a very well developed and well-structured network of women's associations could be instrumental in adding this ingredient of education.
   • Institutionalise health education into avenues such as school curricula and programmes conducted in health facilities. This is a way of investing in current and future basic health knowledge among the country's population.
3. Improve the integration of routine EPI and surveillance of AFP (Acute Flaccid Paralysis) with polio eradication activities:
   In most of the visited countries, NIDs have benefited from a major impetus of creativity and commitment from many people. Communication activities for routine EPI and surveillance of AFP, however, have received limited support and attention. Few materials and activities on routine EPI and surveillance were developed and implemented in visited countries.
   
   

   In addition to the further dissemination of the Communication Handbook for Polio Eradication and EPI and the dissemination of good examples of integrated communication plans, the studies suggest that as much as possible NIDs health education and social mobilization materials should include promotion of EPI and surveillance. This incorporation should be systematic and should be emphasized in the national polio eradication guidelines.
   
   

4. Dedicate resources to conducting quality research
   In at least four of the five countries visited, it was found that data on knowledge, attitudes and practices of the audiences are insufficient or not adequately utilized when they do exist. Yet one cannot plan strategic communication or behaviour-change activities without an in-depth understanding of these audiences.
   
   

   It is emphasized that well-designed in-depth studies that answer key questions, although essential, do not have to be costly. Clearly presented findings should be incorporated into programme and communication planning. There is a need to set aside a minimum amount of funds for conducting formative, operational and qualitative research for advocacy, social mobilization and programme communication. These set-aside funds could benefit not only polio eradication but also EPI and other health issues, if the research is carefully designed. Research should be focused on identifying and defining barriers to ideal behaviours and assessing the factors that facilitate the desired behaviour. Funding and time spent in conducting formative/behavioural research will result in improved development and effectiveness of materials.
   
   

   Furthermore, coordination and dissemination of existing research data should be improved. This will avoid the loss of the benefit of key information when personnel change occurs. An accessible-to-all database is needed at national level in most visited countries.
   
   

5. Develop more strategic communication interventions
   Strategic planning of communication interventions needs strengthening. While a mix of channels are usually used in National Immunisation Days, more strategic planning that takes into account audience characteristics such as gender differences could improve the cost-effectiveness of communication activities. Again, the necessity of research data for research-based strategic planning is emphasised.
   
   

6. Increase and sustain community participation in polio eradication and EPI
   The studies have identified several successful examples of community participation that triggered creativity and solved logistical and strategic issues. For instance, local-leader involvement has particularly helped in successfully reaching hard-to-reach/convince populations. There is ample evidence that community participation has a potential that remains largely untapped.
   
   

   Therefore, the studies indicate the benefits of early and active involvement of communities in all three polio eradication strategies, namely NIDs, EPI and surveillance of AFP. In particular, community participation in surveillance is strongly recommended since previous studies showed that only a limited portion of AFP cases are brought to health facilities. In addition, participation should be, whenever possible, in the areas of assessment, analysis and action, but not limited to passively following instructions received from higher authorities.
   
   

   Within this perspective, immunisation and surveillance data should be regularly fed back to community/district/provincial levels. This could be motivational and could trigger problem-solving, and create an atmosphere of friendly competition among the districts.
   
   

7. Take advantage of momentum and structures created by NIDs to improve routine EPI
   As much as possible, countries should take advantage of the creativity and momentum generated by NIDs to improve EPI. For instance, the studies have suggested:
   • maintaining and supporting intersectoral committees at various levels to promote immunisation and other child health issues. If various committees already exist, improving coordination among those groups to prevent parallel and conflicting activities;
   • devising one or two simple indicators that can also be publicly monitored and then periodically fed back to lower levels (provincial and districts). One possibility is, for example, the percentage of children who are fully immunized when they reach their first birthday. This would create a friendly competition in addition to stimulating problem analysis and action;
   • incorporating EPI information/health education, on a systematic basis into polio eradication materials. Since EPI seems to be presently such a tightly funded programme, why not take advantage as much as possible of the money for polio eradication to revitalize EPI;
   • immunising children for other diseases, particularly when reaching hard-to-reach and/or zero-dose populations during NIDs. At the same time, it could be useful to provide hard-to-reach populations with a basic health education ‘package' (an ‘educational integrated management of childhood illness') that emphasizes immunisation. Although this initiative requires significant additional planning, logistics, training and resources, the overall result could be beneficial and more cost-effective: if these populations are hard to reach during NIDs, they are very likely to be hard to reach for other health services as well.
8. Strengthen monitoring and evaluation and supervisory systems
   Monitoring and evaluation of the communication components of polio eradication and EPI programmes need to be strengthened and should include indicators to assess knowledge, attitudes, practices and behaviours of both health workers and caregivers. Some of the visited countries have supervisory checklists on social mobilisation. However, lists should be expanded to include specific programme communication indicators and clear guidelines for supervisors that are enforced as well.
9. Develop a culture of client-oriented health services
   While caretakers may be easily mobilised to bring their children once or twice to health facilities, if services are not minimally satisfactory or if caretakers feel unwelcome or are uninformed, they will not return for the full series of routine immunisation. There is therefore a need to improve the quality of services and communication activities at immunisation sites. While quality factors are not all directly communication related, the ability of health workers to communicate adequately with caretakers is vital for client-oriented health services. There is a need to establish a continuous system of training and refreshment courses on communication that emphasize IPC for health workers/lay volunteers at all levels, as well as monitoring and supportive supervision of this new culture within the health system. (In fact, the health system treating its personnel more respectfully may well be an essential step for health workers to treat clients better.) This training system should not be only ad hoc but on a continuous basis. Distance education is, for example, an area that merits exploration.
10. Institutionalise partnership with media
    With the above-mentioned perspective of public monitoring and feedback at lower levels, the ongoing partnership of ministries of health and development agencies with the media (national, provincial and community level) could represent the backbone of a public-friendly feedback system. It is suggested that partnership with media be not solicited on an ad-hoc basis but be established and continuously maintained. Public health will definitely benefit from the institutionalisation of such partnership.
    
    

    To this end, it is also suggested that not only media people such as journalists be trained in health issues but health professionals receive exposure to media systems as well.
    
    

11. Develop a long-term partnership with the private sector
    Partnership with the private sector should be expanded and whenever possible institutionalised. A particular emphasis should be put on the involvement of private medical practitioners in polio eradication.