Communication for Immunisation: Nepal's National EPI Plan

Summary:

This presentation begins by defining "full immunization coverage", examining the coverage level in Nepal (2001 as compared to 1996 figures), and describing 2002-03 goals for coverage in this country (80% in 25 districts; 90% in 15 districts). It then focuses on the function of communication in this area, focusing on means for raising awareness (e.g., advertising), changing attitude (e.g., advocating), and changing practices (e.g., mobilising - building alliance and capacity).

Wing-Sie Cheng (who was Chief, Communication - Advocacy & Life Skills Section, UNICEF Nepal when she wrote this) indicates that setting new norms and creating new habits are two key strategies for making immunisation an automatic behaviour ("Once the child is born, I will take him or her to the vaccination post!"). These strategies may contribute to a paradigm shift that, through the use of persuasion, can encourage people to consider changing shifting their negative/reactionary outlooks with regard to vaccination. One strategy is likening vaccination to a product to sell - as a parallel, Cheng suggests comparing the need to sell motorcycle helmets. Among the community of those who can afford to purchase a bike, he says, awareness needs to be built of safety benefits, the purchase needs to be made, and then the purchaser needs to wear the device. The parallel to immunisation would be addressing families, making them aware of the full impact of this practice on health, urging them to bring their children to the health post, and then encouraging them to return for follow-up doses.

According to Cheng, several factors influence communicators' success when it comes to making this communicating for vaccination strategy successful in Nepal. Key factors include identifying audiences (e.g., uneducated mothers), seeking out those who can make vaccination decisions and who can deliver vaccines to those in rural areas (e.g., those who can influence uneducated mothers), and creating messages strategically (e.g., "Come back for your next appointment!" and/or "If your neigbours & relatives have not vaccinated their children, ask them to come to the health post!").

This presentation was also offered in June 2003; UNICEF and GAVI (The Global Alliance for Vaccines & Immunization) held regional workshops in Istanbul, Johannesburg, and Bangkok to address key issues in communication for immunisation. Click here for an overview of these workshops.

What's your goal (2002 – 03)?

Full coverage

• 80% in 25 districts
• 90% in 15 districts

Zero case of wild polio paralysis

80% TT coverage among WCBA in 20 districts

National strategy & action plan for MEASLES control

Introduction of HEPATITIS B

Auto-disposable syringes (?)

HIGH LOW

LOW LOW

Communication is about

• Setting new norms
• Creating new habits

Creating new habits

Paradigm Shift

Persuasion or effective communication

From "No!" to "Yes!"

"Yes!" to No!"

"Maybe" to "Yes" or "No!"

Say you now have a product to sell….

Change the product to vaccine

What's most important? – from the communicator's viewpoint

Who - are you targeting?

How - do you reach them & communicate with them?

What - do you want them to do?

Why - do you want them to change?

It's all about...

Targeting - identifying your audiences

Strategic positioning - what messages to put out, and how to win them over

Target audiences are central

The case of Nike:

Revenues in 1974 - $4.8 million

Revenues in 1996 - $3.4 billion

Now - 24% of the world's market share because it adopts strategic advertising & communication to tackle changing consumers' preference

Nike's tactics

Move sports shoes from an athlete's special wear into people's everyday wardrobe

Target: Teenagers and women

Advertising message:

"We know what you want"

Communication for change

Programme Communication

Mass communication (Social advertising)

Families, parents, men, women, mother-in-laws

One to a group/Interpersonal

Nutrition facilitators, community mobilisers, FCHVs, sanitation motivators

Advocacy

One-to-one

Policymakers, politicians, DDC & VDC chairpersons, etc.

One to many

Media, lobbyists, NGOs, schools, communities

Social mobilisation

Partnership building

Anyone in power, with resources and ability to change

Capacity building

Capacity to deliver

Capacity to change

Important: The problem that has to be solved

Available solutions, and Actions needed to implement the solution

"Mass" media?

40% - Access to TV

90% - Access to radio

35% - Owns a radio set (households)

16% - Access to electricity

40% - Literate (16% women)

Components

A clue…

Those who can make decisions about daughters (& sons)

More clues

Those who can make decisions about daughters (& sons)

Those who can deliver vaccines to hills & mountains

HWs & conservative ethnic groups in Terai

More clues…

Those who can make decisions about daughters (& sons)

Mountain: Western (50%)

Hill: Far West (52%)

Terai: Central & Western (46% – 48%)

Those who can deliver vaccines to hills & mountains

HWs & conservative ethnic groups in Terai

Even more clues…

Those who can make decisions about daughters (& sons)

Those who can deliver vaccines to Far Western hills & Western mountains

HWs & conservative ethnic groups in Central & Western Terai

Uneducated & educated mothers

On Messages

Drop out

• Parents unaware of full immunisation
• Health workers or FCHVs do not tell them
• HWs do not discuss possible side effects nor inform mothers that child with fever can be vaccinated

Confusion

• OPV = other vaccines & fear of overdose

Wrong expectation

• Routine immunisation = House to house visits

Ignorance & gender biases

Primary targets

• Uneducated mothers
• Those who can influence uneducated mothers
• Mothers with some education

Addressing what?

Drop out: “Come back for your next appointment!”

Reach out: “If your neigbours & relatives have not vaccinated their children, ask them to come to the health post!”

Clarify: “OPV is one of the 8 antigens – and you must complete the other 7!”

House-to-house applies only to OPV

Secondary targets

• FCHVs (health educators)
• Health workers (also health educators)
• National & local leaders, who can improve logistics and motivate FCHVs & HWs (eg. Devising awards "best HW of the year"
• Opinion leaders who can influence families

As for Hepatitis B & ADS

• An entirely new round of radio & TV spots, posters and leaflets – raise mass awareness
• Targeting Mothers, Fathers, In-Laws, leaders and HWs
• TOT of HWs on Hep B & auto-disposable syringes
• Political & media advocacy

Combined interventions by phase (an example)

Oct - Feb

Message Themes: NIDs - OPV DPT Vaccines

Radio & TV: Radio/TV spots; Edutainment prog.

IPC: District outreach with messages (eg. Loudspeakers)

Training & mobilisation at Districts: FCHV orientation; TOT plan; Meeting with leaders

National advocacy: National launch of Hep B by PM, MOH

Feb - May

Message Themes: Measles; NIDs - OPV; Introduce Hep B

Radio & TV: Radio/TV spots; Edutainment prog.

IPC: District outreach (eg. "miking")

Training & mobilisation at Districts: TOT Health Workers; FCHV orientation

National advocacy: Media orientation

May - Sept

Message Themes: BCG; DPT; NID - OPV

Radio & TV: Radio/TV spots; Edutainment prog.

IPC: District outreach

Training & mobilisation at Districts: TOT; HW award scheme; FCHV award scheme

National advocacy: Polio eradication announcements

Sept - Feb

Message Themes: Hep B; NID - OPV; Measles

Radio & TV: Radio/TV spots; Edutainment prog.

IPC: District outreach

Training & mobilisation at Districts: TOT; Best HW of the year; Best FCHV of the month, etc.

National advocacy: Release of Hep B video on NTV Special chat-show over Radio Nepal

HWs + Skills

New communication paradigm (late 1990s)

Information plus

• Knowledge, Attitude and Practice (KAP) to
• Knowledge, Attitude, Practice and Skills (KAPS)

Not just about imparting knowledge

• Skills to communicate
• Skills to solve problems
• Skills to help mothers/families make INFORMED CHOICES and DECISIONS

Proposed Communication Budget for EPI

II - TV and Radio Spots - Production and Airing

III - Pre-testing

Total Communication Budget Estimate

• US$ calculated at NRs. 77.55
• KAPS or rapid assessment of audience's attitude to be funded out of regular communication
  
  budget (not included here)
• Regional Service of Nepal Radio and Regional FMs cost much less but we will need to buy time from 4 or 5 different regional stations if we want to reach nationally. Thus it would be more cost effective to buy time on National Service of Radio Nepal and we get to reach the maximum number of listeners.
• Regional - R. Nepal NRs. 800/ spot for 52 weeks NRs. 1,248,000
• Regional FMs NRs. 650/spot for 52 weeks NRs. 1,014,000

Thank you.

Click here to download a Power Point Presentation of this document.