VIEW POINT

Communication: A Key Element in Leveraging Routine Immunization

Dr. M Dobe*

*Director- Professor & Head, Department of Health Promotion & Education All India Institute of Hygiene & Public Health, Kolkata

Mission Indradhanush

The Government of India has launched the Mission Indradhanush1on 25 December 2014 as a special drive to vaccinate all unvaccinated and partially vaccinated children and pregnant women by 2020 under the Universal Immunization Programme. The Mission Indradhanush, depicting seven colours of the rainbow, targets to immunize all children against seven vaccine preventable diseases namely Diphtheria, Pertussis, Tetanus, Childhood Tuberculosis, Polio, Hepatitis B and Measles.

India has one of the largest Universal Immunization Programs (UIP) in the world. However, since the launch of Universal Immunization Programme in 1985, full immunization coverage in India has not surpassed 65%.

Mission Indradhanush focuses on interventions to expand this coverage to more than 90% children by 2020.

Under Mission Indradhanush2,the Government has identified 201 high focus districts across the country. Nearly 50% of all unvaccinated or partially vaccinated children in India are in these 201 districts. Intensified routine immunization campaigns in these districts will be done through special catch-up campaigns to rapidly increase full immunization coverage.

The broad strategy, based on evidence and best practices, has effective communication as one of its major focus areas, for generation of awareness and demand for the routine immunization program. In this context, we need to look into the lessons learnt and the challenges identified.

The story of Immunization has been one of successes and failures. The push to universal immunization in the 1980s, accelerated immunization coverage. Yet, immunization services still disproportionately miss the poorest and most excluded populations and even when services are available, a substantial number of caregivers still fail to complete the immunization schedule

Awareness regarding the routine immunization program has been the major challenge in demand generation for these services. A substantial number of children do not complete immunization schedules because neither health services nor conventional communication mechanisms regularly reach their communities.

Studies show that knowledge gaps underlie low compliance with vaccination schedules. Caregivers are less likely to complete immunization schedules if they are poorly informed about the need for immunization, logistics (time, date, and place of vaccination), and the appropriate series of vaccines to be followed3. Although knowledge per se is insufficient to create demand, poor knowledge about the need for vaccination and when the next vaccination is due is a good predictor of poor compliance. A complexity of political, epidemiological, economic, and social factors underlie these challenges. Information about burden of disease, cost-effectiveness of vaccines, and demand is central to the process.

We need to remember that persuading these populations to accept vaccination is not simply a matter of disseminating knowledge about vaccines. Knowing about vaccination, although important, does not necessarily lead to immunization acceptance. The impact of awareness on actual immunization behaviour is modified by socio-cultural and political influences - such situations call for locally appropriate communication responses. Innovative outreach strategies are needed that are particularly targeted to reach children who are excluded or beyond the reach of immunization services.

A number of studies have documented the impact of mass media4 — particularly radio and television — on awareness and vaccination rates. Findings generally report an increase in knowledge about the benefits of vaccines, ages for immunization, and places and time of vaccinations; improved perceptions of seriousness of some diseases and positive shifts in attitudes regarding childhood vaccination; and more discussion about immunization in the home.

Building and maintaining trust and confidence in routine immunization programs has also been one of the major challenges. Ever since inception, entire populations have never completely trusted and accepted scientific endorsements of specific vaccines and immunization in general. Even in areas where majority of caregivers accepted vaccines and were motivated to comply with vaccination schedules, immunization programs encountered pockets of refusal and resistance.

Historically, populations have rejected immunization due to concerns about vaccine safety, as well as political, cultural, and religious reasons3.

Trust and acceptance of immunization faces, formidable challenges:

A paradoxical situation emerges as immunization programs become victims of their own success. Individuals and communities feel less threatened by the less visible vaccine-preventable diseases than by the side effects of vaccines. Caregivers may have more information and awareness about adverse events than about the benefits of immunization and the need to sustain immunization. Also, for caregivers, immunization decisions are part of culturally grounded estimations about dangers and benefits that need to be addressed.

Evidence reveals that communication is particularly needed to build trust in vaccines among those who question them. A mix of media and locally appropriate, community-based strategies is needed to address concerns and refusal. In any situation where the safety of vaccines is questioned, it is critical to first understand the nature and scope of the concerns. Interpersonal communication activities with influential local leaders (religious, medical, and political) can positively affect the community’s trust in and willingness to vaccinate their children. Community leaders can not only be valuable partners in social mobilization, they can be valuable key informants to understand the nature and reasons for any concerns regarding routine immunization. Promoting immunization through advocacy in community networks is a proven means to build trust and acceptance of vaccines.

Another significant challenge is the quality of the interaction between health workers and caregivers, which has been proved to be is decisive to ensure completion of the vaccination schedule.

High dropout rates and caregivers’ negative attitudes about immunization services are often due to poor or inadequate information-sharing by health care providers5. The failure of health care providers to communicate correct information about vaccine effects and schedules, to check whether caregivers know and understand information, and to give them opportunities to ask questions, partially account for incomplete vaccination of young children. Specific behaviours by vaccinators such as rudeness and insensitivity deter caregivers, who are dissatisfied and therefore become less motivated to return to health facilities to complete the vaccine schedule. Health workers are one of the most influential sources of information in affecting vaccination behaviour, effective interpersonal communication between health care providers and caregivers is critical. This is even more important as caregivers need to know and be reminded of new vaccines added to the immunization schedule.

Health care providers need to be trained and adequately supervised to ensure that they give relevant and comprehensible information in a respectful and culturally sensitive manner. Health system needs to be reoriented for facilitation of application and monitoring the use of relevant skills of the provider. Effective communication interventions can increase demand, but if the quality of services is poor, many caregivers are not likely to return to complete schedules.

We need to remember that:

There are no one-size-fits-all in communication. Tailored messages using appropriate channels are required to reach specific segments of the population. Tailoring needs to be done on the basis of information distinguishing knowledge and attitudes among users, non-users, and “inconsistent” users (“dropouts”) of immunization services.

Proactive communication is needed in a sustained manner to curtail and prevent negative publicity and resistance to immunization, and to build continuous trust in vaccination programs by working with opinion leaders who influence caregivers’ perceptions and behaviours

Ensuring positive attitudes and good interpersonal communication skills of frontline health workers through use of well-designed, easy-to-use communication tools and interpersonal communication skill-building programs are decisive to promote long-term compliance. Strengthening and supervising communication skills of health care providers should be integral to immunization planning and training.

Advocacy coalitions6 are key to successful immunization programs and has been reinforced in polio elimination. Such coalitions can propagate success stories and good practices. Advocacy briefs also need to use evidence to show the benefits and cost effectiveness of vaccination over other health interventions.

Demand creation and damage control are the two major aims of effective communication for leveraging routine immunization coverage

Coverage data and qualitative research needs to be used to target caregivers of children who are “left out.” “Dropout” problems as well as missed opportunities need to be analysed through exit interviews and observations. Better understanding of health worker-client communication is also essential because for enhancing full immunization, health worker behaviours are especially critical. We know every parent wants what’s best for his or her child and would go to great lengths to avoid harm, so adequate, appropriate and timely health communication will lead to success of Mission Indradhanush and leverage full immunization coverage towards the desired goal.

References:

  1. Ministry of Health & Family Welfare, GoI, Mission Indradhanush: http://www.nhp.gov.in/health-programmes/national-health-programmes/mission-indradhanush accessed on 5.5.15
  2. Ministry of Health & Family Welfare, GoI, Mission Indradhanush Operational Guidelines 2015
    upnrhm.gov.in/.../Mission_Indradhanush_ _Operational_Guidelines.pdf accessed on 5.5.15
  3. Silvio Waisbord Heidi J. Larson Why Invest in Communication for Immunization? Evidence and Lessons Learned :
    www.who.int/immunization/.../why_invest_in_communication_for_imm... Accessed on 5.5.15
  4. UNICEF - Building Trust in Immunization. Partnering with the Media. Working paper UNICEF 2004.
    www.unicef.org/.../Immunisation_report_17May_05 accessed on 4.5.15
  5. Children’s Vaccine Program. Realizing the Full Potential of Childhood Immunization - How Health Professionals can Make a Difference.
    http://childrensvaccine.org/files/CVP_Occ_Paper1.pdf accessed on 5.5.15
  6. GAVI. 2001. Advocacy for Immunization: How to generate and maintain support of vaccine programs. http://www.childrensvaccine.org/files/GAVI-AdvocacyHandbook.pdf 18 accessed on 5.5.15