Understanding Immunization and Vitamin A Communication in Rural Cambodia: A Formative Research Study

"The development of an effective behavior change communication strategy requires an indepth understanding of the many stakeholder viewpoints, perceptions, and norms. There is considerable evidence that focused messages to inform parents about where and when to go for complete immunization is the most important and effective communication strategy. However, it is critical to understand the social-communication environment for maximum effectiveness of both community mobilization and interpersonal communication approaches."

This report describes a study whose primary objective was to inform the development of a communication strategy to improve immunisation coverage in Angkor Chum Operational Health District of Siem Reap, Cambodia, while supporting the National Immunization Program's efforts to enhance national-level programming. The impetus for the study is the fact that the Health Sector Strategic Plan 2003-2007 articulated the aim to fully immunise 80% of children below one year of age by 2007, from 2004 to 2005, routine service statistic coverage estimates for Bacillus Calmette-Guérin (BCG), diphtheria, pertussis (whooping cough), and tetanus (DPT3), measles, oral polio vaccine (OPV)3, and vitamin A had stagnated. "Well-developed and targeted communication strategies can play an increasingly important role in achieving and maintaining coverage targets."

Conducted by the Cambodian Red Cross (CRC) through the United States Agency for International Development (USAID) Child Survival and Health Grants Program (CSHGP), the study was designed in collaboration with various stakeholders. Five modules were developed focusing on different aspects of vaccination and vitamin A service delivery including: (i) best practices and system constraints, (ii) communications, (iii) interpersonal communication (IPC), (iv) barriers, and (v) key benefits and messaging. Data collection methods included in-depth interviews, service delivery observation, convenience sample, and focus group discussions (FGDs). The methodology is articulated in detail within the document.

Selected communication-related findings and recommendations include:

1. Finding: IPC with each mother through home visits is a critical factor to motivate immunisation-seeking behaviour and achieve high coverage. However, village leaders and Village Health Support Groups (VHSGs) often do not have time to visit each house. Furthermore, caregivers, particularly caregivers of children "not on schedule", want to be reminded in their home about health centre outreach one day before the session. Recommendations: "Volunteer and communication networks should be mobilized in the community to disseminate the outreach schedule as well as encourage caregivers to seek vaccination services for their children. Volunteers, including Red Cross volunteers, should be responsible to their communities for completing a manageable number of home visits to remind families to attend outreach one day prior to the outreach visit. It is important to motivate volunteers to develop a personal relationship with each household with whom they work. This will permit them to better understand barriers and resistances, personalize messaging, and negotiate more effectively to improve attendance for health center services." Also, several village leaders and VHSG members recommended setting up small committees or village-based teams to help them get the word out and disseminate health information throughout the village.
2. Finding: Caregivers report that they often share information about health centre outreach sessions with their family and neighbours, yet say they do not receive information from the same people. Recommendations: "A 'neighbor-to-neighbor' campaign should be developed to encourage and formalize the practice of sharing information related to outreach scheduling." Also suggested: Mothers with fully vaccinated children should teach and motivate their neighbours, such as those with "not-on-schedule" children, to come for immunisation services.
3. Finding: "Advance notification of the outreach schedule to the village varies and is often not adequate to permit proper dissemination of information throughout the village by VHSGs and village leaders." Recommendation: "Health centers should standardize the practice of informing village leaders and VHSGs at least two days before outreach. Village leaders recommended that information is provided both by letter and verbally at least two to four days before the activity."
4. Finding: "Buddhist monks and nuns, as well as schoolteachers, are highly respected community members; however, their participation in promoting immunization services is presently limited." Recommendations: "Pagodas [places of worship] should be engaged to play pre-recorded immunization radio spots one day prior to scheduled outreach sessions using the pagoda loudspeaker system. The radio spots should be the same so that people always associate it with immunizations. Bullhorns should also be used to promote outreach sessions. Teachers should also be engaged to educate school children about immunization and vitamin A. Teachers can also disseminate information about scheduled outreach sessions to students in order to pass this information along to their parents and neighbors."
5. Findings: "Health center staff members consider their primary achievement to be the completion of 'full coverage.' By contrast, village leaders and VHSGs had difficulty identifying their achievements. Furthermore, immunization record keeping in the village is a critical factor as this information permits both village leaders and VHSG to go directly to those households needing follow up." Recommendations: "The common goal of 'full coverage' should be discussed, defined, and understood among all key immunization stakeholders, especially village leaders and VHSGs. This discussion should serve as a basis for the development of a common plan to achieve 'full coverage' to be monitored through the village record keeping system. Additionally, a village recognition system such as health certification or raising a flag to identify that the village has achieved its full coverage target should be developed."
6. Findings: "Good planning and cooperation, as well the development of a positive relationship with villagers, village-level volunteers, and village leaders, as identified by health center staff, is critical...[Furthermore, r]oles and responsibilities of immunization stakeholders are not clear or well-understood..." Recommendations: "Relationships among key immunization stakeholders should be strengthened. This may be achieved through reactivating full participation of stakeholders in monthly health center coordination (VHSG) meetings....Health center staff should publicly recognize the role of village leaders as advocates and capitalize on their strong belief related to the effectiveness of vaccines. Village leaders should be empowered to maximize their influence in getting caregivers to seek health center services. Additionally, the results of this study should be disseminated among stakeholders at all levels..."
7. Finding: "Health center staff most commonly cited the need to educate TBAs [traditional birth attendants] on the importance of the HepB [hepatitis B] birth dose. All health center staff identified the need to be informed immediately following childbirth....However, there is no uniform system for tracking and reporting newborns to the health center." Recommendation: "A localized birth notification plan should be developed among key immunization stakeholders....The plan should be linked to the national birth registration system."
8. Finding: "The benefits of tetanus toxoid (TT) are not well understood among caregivers." Recommendation: Develop a communication campaign focusing on the benefits of TT immunisation.
9. Finding: "Caregivers had difficultly recalling any vitamin A messages on their own or expressing how they would convince their neighbor to bring their children for vitamin A capsules. However, when key vitamin A messages were read out loud, most caregivers were able to identify them..." Recommendation: Focusing on IPC, "health stakeholders should promote vitamin A key messages throughout the year. They should emphasize the benefits of consuming vitamin A rich foods that are accessible and available to caregivers in the village."
10. Finding: "Some health centers offer priority and/or free services to VHSGs and village leaders as an incentive for collaboration. This is a highly valued and appreciated benefit." Recommendation: Standardise, institutionalise, and expand this practice.
11. Finding: "Outreach sessions are almost exclusively focused on immunization services. During expanded outreach, vitamin A and mebendazole are also included. The growth-monitoring chart on the back of the yellow card immunization record is not used." Recommendation: "Outreach sessions should be viewed as a platform upon which other services can be offered..."
12. Finding: Outreach staff report they do not have enough time to provide health education during sessions. Recommendation: Designate one person to explain vaccinations during outreach sessions to improve demand.
13. Finding: Health center outreach staff did not directly observe oral ingestion of mebendazole distributed during expanded outreach. Recommendation: Clearly assign the responsibility of providing water and observing oral ingestion to village leaders, VHSG members, or village-based volunteers.
14. Finding: While caregivers perceive the yellow immunisation card to be an important document, it is susceptible to water damage. Recommendation: Provide plastic covers.
15. Finding: "[T]here is a need to reinforce communication related to completing vaccines given as part of a series as well as associating vaccination dates with other days of significance such as holidays." Recommendation: Provide practical training to health centre staff to refresh IPC skills using adult-learning methodologies.
16. Finding: The primary barrier for villagers to go to the health centre for services is distance and related travel costs. Recommendation: "Fixed-site vaccination services should be scaled up over time to all villages near health centers. Communities should have maximum feasible participation to ensure vaccination service seeking at the health center."