Communication for Immunization Campaigns for Maternal and Neonatal Tetanus Elimination

"...[C]ampaigns and routine immunization activities are more effective (i.e., more people participate, thereby increasing prevention of illness and death) when program planners engage key groups and sectors in society to bring about collective change. Save the Children considers social mobilization to be a planned process to increase demand for and acceptance of immunization services, clean delivery, and other positive practices to improve maternal and newborn health."

The purpose of this guide is to describe how to design and carry out a social mobilisation programme to create demand and increase participation during immunisation campaigns and routine immunisation (RI), and thereby improve the health of communities in developing countries. The approach described here was developed and used by the Saving Newborn Lives (SNL) initiative of Save the Children/United States (US) in maternal and neonatal tetanus (MNT) immunisation campaigns in Ethiopia, Mali, and Pakistan. From 2001-2005, Save the Children and the United Nations Children's Fund (UNICEF) teamed up with the governments of these 3 countries in large-scale campaigns to eliminate tetanus. In Pakistan alone, NT deaths were halved (from 28,000 annually to 14,000). During the same period, UNICEF and other partners provided technical and financial support for MNT elimination activities in 38 other countries to reach the elimination goal by 2005. According to Save the Children, communication and social mobilisation activities helped these countries achieve high coverage by building community demand. This guide has collected the "best practices" and lessons learned from designing and carrying out the campaigns, focusing on communication activities, and presents these lessons so they can be used in other immunisation programmes for women and children.

A background section of the paper explains that each year an estimated 180,000 newborns die from neonatal tetanus (NT) and that maternal tetanus also takes the lives of approximately 30,000 women every year. However, Save the Children argues that the number of deaths from tetanus is higher than official government statistics, which is why tetanus is sometimes known as the "silent killer".

As described in this guide, an effective social mobilisation programme to address vaccination for this (or any other) disease has 3 phases - each of which consists of a number of steps that are described in some detail in the guide:

• Phase I. Gathering information
• Phase II. Designing a social mobilisation strategy
• Phase III. Carrying out social mobilisation activities

The centrepiece of a social mobilisation programme, according to Save the Children, is the communication strategy: a comprehensive plan outlining strategic activities to provide information to intended audiences, create a supportive environment for individual and collective change, and promote and facilitate the adoption of specific positive behaviours. The intended audiences include those who will be getting the immunisation, health workers who will be vaccinating mothers, and people who work for organisations and government agencies that will be supporting the campaign. Yet another key audience of social mobilisation, per Save the Children, are "key influentials" such as opinion and religious leaders, family members (especially husbands and mothers-in-law), close friends, and others women talk and listen to when making decisions about their health.

From Save the Children's experiences, interpersonal communication (IPC) - which involves marshalling health workers and community volunteers to explain key messages, respond to questions, demonstrate skills, and negotiate doable actions with individuals and communities - is critical to changing behaviour and so should be the backbone of all immunisation communication strategies. For example, women and their babies are much less likely to be exposed to the disease if skilled midwives or traditional birth attendants (TBAs) talk with families about the importance of clean delivery practices.

As detailed here, communication especially plays a role in remote populations where local belief systems, cultural practices, and lack of information may prevent people from asking for and receiving immunisations. Communities may not recognise the link between unclean delivery practices and disease; for example, some people believe that convulsions are caused by witchcraft rather than from tetanus caused by unclean cord care. Incorrect ideas about the vaccines are common. For instance, in many countries the mistaken belief that TT vaccination is a family planning or sterilisation method is prevalent. According to Save the children, an effective communication strategy can directly address many of these problems in at least 3 ways: by making more people aware of the benefits of immunisation; by correcting false beliefs, rumours, or concerns that prevent people from getting immunised; and by informing people where and when to get immunised. "Communication efforts are more effective in creating and maintaining demand, especially in the high-risk areas described above, when they are part of an overall social mobilization program to reach, influence, and involve a broad range of groups in support of immunization. Serious advances can be made only when large numbers of people begin to know more and care more and do more. Communication [is] an essential part of this process."

Save the Children stresses that, to the extent possible, social mobilisation and communication activities should be designed not only to create demand during the campaign period, but also to create demand for RI. One strategy described here is involving the community and various local and regional partners in all aspects of the campaign so that, when the campaign is over, "[t]ogether they can help keep the messages of the campaign alive."

In designing the communication and social mobilisation strategy as part of the work described in the document, the key question for Save the Children was: What combination of strategic activities and communication tools is necessary to create demand for a health activity or service, especially one that the majority of the population may not perceive as either necessary or beneficial? This guide records how Save the Children answered that question....We must never lose sight of the fact that at the end of the day the real goal of social mobilization is to create a world where immunization is so common that campaigns are no longer needed."