Immunization Campaigns: Mitigating Barriers - Designing Communication

"[W]eak or inadequate communication can contribute to a great extent, to vaccine hesitancy and thus negatively influence vaccination uptake."

Despite efforts by governments around the world to address supply aspects of vaccination, social scientists continue to face challenges with the demand generation dimensions of immunisation programmes. Ensuring sustainable demand for immunisation is only possible when caregivers and communities trust the safety and efficacy of vaccines, as well as the quality and reliability of immunisation services. Therefore, the health-seeking behaviour aspects of individuals and their respective communities play a significant role in achieving immunisation coverage. In that light, this paper presents a model called the Vaccination Communication Model (VCM), which provides a modular approach for facilitating design of an immunisation communication strategy.

The paper revisits varied conceptual frameworks of strategic communication that are applicable to the vaccination challenges immunisation programmes are confronted with, particularly in light of how critical it is to ensure addressing "last-mile" gaps in reaching all children. It is based on consolidated reflections gathered through varied field experiences and study of programme approaches. It emphasises the need to ensure social-inclusion of vulnerable, hard-to-reach, and economically poor people in bringing about positive vaccination-related behaviour change in communities. This focus reflects an acknowledgement that immunisation coverage may be affected by social determinants; thus, on this understanding, it is critical to address those differences in uptake that arise from inequity in vaccine delivery and access.

Specifically, the authors explain that much of the research in the field of social and behaviour change communication (SBCC) for health, especially routine immunisation in many developing countries, reveals that efforts around social mobilisation and community-based communication have witnessed broader conceptual and theoretical shifts over a period of time (information, education, and communication (IEC) materials >> programme communication >> health promotion/education >> SBCC). In fostering sustained SBCC interventions in communities, within the gamut of development and health programmes, the proponents of various communication theories and frameworks have cited how social change takes place and how a positive and progressive change is communicated through select communication channels over a period of time to individuals, communities, and society.

On the SBCC approach, it is within communities that the reality of development is experienced; thus, community participation in the design and implementation of health and development programmes is essential to the positive change process. Alternative communication (local and community-owned) systems and media practices are regarded as significant means for local people to engage in health and development activities, and as a two-way process in which communities can participate as key change-agents in evolving toward more positive behaviours/practices. Inherent to the paradigm is an increased priority on horizontal, multi-directional communication methods that utilise a mix of channels and that emphasise the importance of sustained dialogue in facilitating trust and mutual understanding. The goal is to provide adequate space to the voices of socially excluded and disempowered people and to empower them to identify ways of overcoming the targeted problems in order to improve their own health and well-being.

A set of recommended interventions under the VCM employs 4 primary theoretical conceptual frameworks in strategic health communication, which are outlined in the paper - namely: Theory of Diffusion of Innovations (Evert M. Rogers); the Theory of Planned Behaviour (Icek Ajzen); Stages of Change Theory (Prochaska, DiClemente & Norcross); and the Health Belief Model (Hochbaum & Rosenstock). In the process of behaviour change, the ultimate end result is also gauged by the number of change-catalysts termed as advocacy-agents, who in turn serve as positive deviants in a given community. These are converted advocates of a given health behaviour such as adhering to a complete prescribed vaccination schedule, as they not only practice it but also serve as positive examples in a given community. The positive deviance (PD) approach offers a systematic framework to identify assets, indigenous knowledge, and home-grown solutions, and to amplify them for wider adoption.

Of various media approaches, the VCM is based on an integrated approach (a strategic mix of mass media and interpersonal communication), described here (see Figure 2, above) as a sustained approach to reach out to and engage with communities, educate people, and foster positive change. Such a campaign design combines mass media for awareness and branding with strategic use of interpersonal approaches in reaching out to individual households and caregivers in order to bring about positive behaviour change for promoting vaccination.

However, translating and effectively converting technical information and complex socio-behavioural messages into creative, appealing, and acceptable approaches that trigger sustained dialogue among participants can be a difficult and daunting task. Therefore, as outlined here, the immunisation campaign needs to draw as its starting point on both the "felt needs" at community or local level and the "action needs" as identified through risk-factor analysis. Specifically, on the VCM, the process of addressing the barriers that individuals and the community face, and thus empowering them through "enablers", is key to achieving the vaccination success. To that end, a multi-page chart in the report lays out a series of barriers (risk factors), enablers [proximate determinant(s)], and strategic communication actions.

The operational immunisation campaign strategy for meeting "felt needs" and "action needs" ideally follows 4 stages of activities:

1. Identifying and analysing the innovations sought by the community and those that the programme desires to introduce to whom, when, and with what material means. This is generally known as the diffusion stage in the conceptual framework of development or strategic health communication.
2. Determining how existing social, cultural, psychological, and indigenous communication factors, as well as government organisational factors, would help or hinder the adoption of (or adherence to) new practices and behaviours. This is also known as the social process stage.
3. Consolidating efforts towards identifying available media at the field level and how they relate with the people, including hard-to-reach and vulnerable populations. At this stage, the campaign team should assess existing combinations of communication channels - traditional and interpersonal channels, as well as modern print and electronic media - and how they can be used most effectively for communication "feed" both into and from the community.
4. Creating and implementing locally tailored communication interventions in phases, where the real action potential is in the communities. This process entails taking into account available supplementary inputs from outside the community, which are positioned to complement the strategic process of SBCC for sustained practice of routine immunisation.

In the global context, the process of designing a SBCC strategy in fostering strengthened immunisation programmes reinforces the prevailing perception that there is a clear need to move beyond measuring the difference between worst- and best-performing geographical areas and to accurately identify who or which groups are not being immunised and where (and why). The process of risk-factor analysis and community-level consultation facilitates a participatory approach; therefore, it further strengthens the campaign-design process in choosing the most appropriate communication tools, strategic messages, and the linked interventions for the vulnerable and the hard-to-reach populace. This process also supports the mandate of equity and social inclusion. Figure 3 in the paper outlines an approach for ensuring that all individuals and communities are reached in their respective countries, in line with the mandate of equity.

Based on the framework and analysis presented here, the authors conclude: "It is clear that the strategic-communication offers feasible strategies for reducing both service and consumer barriers to foster complete coverage and for promoting and sustaining positive immunization behaviour among these groups on a long-term basis."