Integrating and Supporting Expanded Program on Immunization (EPI) Communication

In this presentation, Lora Shimp discusses the communication implications for the Expanded Programme on Immunization (EPI), which involves country immunisation programmes supported by World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and other partners to combat diseases such as polio, measles, neonatal tetanus, diphtheria, pertussis (whooping cough), tuberculosis, hepatitis B, and yellow fever. EPI also addresses vaccine prices, quality, and supply; the need to enhance recognition of the value of vaccines; the cost of vaccine development and improvement; and strategies for improving immunisation practices.

Shimp is Immunization Technical Officer at BASICS, or Basic Support for Institutionalizing Child Survival. BASICS II is being conducted from 1999-2004; it is an initiative of The U.S. Agency for International Development (USAID).

This presentation, and Shimp's summary (below), focusses on the activities and recommendations of the Communication Advisory Group (CAG), which includes participation from a variety of organisations working in immunisation communication.

Summary provided by the presenter

Since its formation in 1997, the Communication Advisory Group (CAG) of multi-agency partners has been working with the Task Force for Immunization in Africa (TFI) to improve communication support and activities for immunisation programmes. In 2002, the TFI recommended that communication monitoring and evaluation indicators be developed and utilised to better demonstrate the contribution of communication to EPI improvements. Data collected were also to be used to improve the performance of communication activities. In addition, increased resources for communication, as well as capacity building on communication for health personnel and service providers, were also recommended.

In 2003 and 2004, the CAG has been implementing these recommendations through the briefing of sub-regional working groups and ICCs [inter-agency coordinating committees] to promote the communication component within EPI. Joint communication technical assistance is also being provided to countries, including training in communication monitoring and use of indicators as well as integration of the communication component into "reaching every district" (RED) approaches and mid-level EPI manager trainings. In its biannual meeting in June 2003, the CAG discussed the need for an advocacy approach to further pressure governments to ensure the quality of immunisation services, including communication. Immunisation programmes are also being encouraged to promote client-based service delivery, stressing caregiver, community and health staff satisfaction and collaboration to improve the demand for and provision of services. To assist with this, it was agreed at the 2004 TFI meeting that communication positions are needed to work with EPI on routine, GAVI [Global Alliance for Vaccines and Immunization], RED, and disease-specific interventions (e.g. polio and measles campaigns and community surveillance). Financial and technical support for immunisation communication capacity building is also needed at regional and country levels.

What can this immunisation communication support provide in practical terms? Recent analysis of immunisation programmes has shown that drop-out (i.e. infants who begin their vaccination schedule but do not complete the vaccination series) remains a problem in many districts. Efforts to reduce drop-out are part of the RED approach, in which communication plays a key role. Service delivery improvements are needed, including implementation of revised policies, improvements in data reporting and tracking of defaulters, active screening of vaccination status of sick children, and reorganisation of vaccination sessions and outreach with communities. Communication activities can further enhance these efforts. For example, communication between health workers and communities can be improved to build awareness of vaccination and improve planning of services. Vaccination cards can also be more actively used to track children's vaccination status as well as to provide information to caregivers on the vaccination schedule and the need for return visits to complete the vaccination series. To improve communication, activities need to utilise existing community networks, ensure the quality of services, and provide information through various mass media and inter-personal channels. Within districts, the communication activities should be linked to EPI strategies for improving coverage and reducing drop-out. In addition to coverage data, social/demographic data are also needed and can be collected through rapid assessments, to develop appropriate communication strategies that will support the immunisation programme.

In Madagascar, for example, drop-out rates are being reduced in districts through a three tiered approach that involves strengthening health worker skills (including communication), improving the health system and quality of services, and promoting positive family and community behaviours. Operations research conducted in 2003 with health workers and communities in 10 districts in Madagascar identified several problems with immunisation services and communication. These included poor knowledge of caregivers on the advantages of vaccination; low awareness of services among the population; lack and/or inconvenience of outreach services; negative health worker behaviour towards caregivers; insufficient community mobilisation, including lack of involvement of local leaders; and various beliefs, customs and rumors that discouraged or caused doubts related to immunisation services. As a result of these findings, a new strategy for EPI communication was implemented as part of RED activities in 20 focus districts in the heavily populated provinces of Antananarivo and Fianarantsoa. (These provinces account for approximately 45% of the total population of Madagascar). Activities implemented in the districts include the use of supervisory guidelines for community activities that also address EPI communication; further elaboration and standardisation of key EPI messages (e.g. five contacts for vaccinations, completion of schedule before first birthday) and materials (e.g. vaccination diploma, child health card, countdown flags for vaccination days); and increased involvement of local leaders, mass media, and other government programmes outside of the MOH [Ministry of Health] in re-launching and promoting EPI within community development. Immunisation communication is therefore integrated not only with health staff capacity building, but also into activities of community groups and leaders as well as volunteer community mobilisers who provide information to the public. In the focus districts in Antananarivo and Fianarantsoa, this resulted in 2003 DPT/HepB3 coverage reported at 84.9% and 78.3% respectively. In addition, Antananarivo and Fianarantsoa were among the leading provinces in Madagascar in 2003, reporting DPT/HepB3 coverage of approximately 73.4% and 68.6% respectively, with the national average at 66.6%. Drop-out rates for the provinces in 2003 were also improved from 2002. Antananarivo's DPT/HebB drop-out rate reduced from a reported 8% in 2002 to less than 2% in 2003. Fianarantsoa's drop-out rate reduced from a reported 19% in 2002 to approximately 13% in 2003. Activities are continuing in 2004, for longer-term impact on improvements in immunisation coverage in these districts and provinces as well as to monitor and document the experience for potential application nationwide.

Similar communication approaches are being implemented with RED activities in other countries. For immunisation communication to achieve success in these programmes, continued support and integration with EPI priorities and work-plans are needed. In its November 2004 annual meeting, the CAG recommended the following to the TFI:

• Increased financing and support for communication as a component of routine EPI and with accelerated disease control efforts, to enable more effective community linkages, advocacy support and social mobilisation for immunisation;
• Funding for communication positions at global, regional, and national levels to support national and district-level immunisation activities;
• Communication technical support and capacity building for and within countries, particularly to support RED and GAVI activities, including strengthening service delivery and improving communication linkages at district and community levels. (For example, to improve outreach planning and implementation, health worker and caregiver inter-personal communication, linking health centres with communities and local leaders, and improved use of media for advocacy and mobilisation.)

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