How to Immunize 35 Million Children in 60 Days?

This presentation highlights the role of behaviour change communication, advocacy, and community mobilisation in addressing behavioural-related challenges for childhood immunisation. It does so through by sharing the experiences of, and lessons learned from, the Indonesia measles-rubella (MR) campaign carried out by the United Nations Children's Fund (UNICEF) and partners in support of the Ministry of Health (MOH). Conducted August-September 2017, Phase 1 sought to reach 35 million children age 9 months to 14 years of age in Java Island; Phase 2 is being implemented in 2018 in 28 provinces outside Java, attempting to reach 33 million children from the same age group.

Syafitri provides background to explain the impetus for the campaign. Immunisation activities have been implemented in Indonesia for 30 years with the goal of reducing morbidity and mortality due to vaccine-preventable diseases such as tuberculosis, diphtheria, pertussis, tetanus, polio, and measles. According to a World Health Organization (WHO)/UNICEF joint report (2017), Indonesia is one of the six countries with the highest of unimmunised children. Basic immunisation coverage decreased from 93% in 2011 to 86% in 2015; currently only 82% of children in Indonesia are currently immunised against measles, with this rate falling to below 60% in the eastern part of the country. Disparities exist in the quality and coverage of health services across provinces and districts, including for immunisation.

An immunisation drop-out survey on Java Island, Indonesia revealed communication and behavioral-related challenges that hinder immunisation uptake.

• Low level of awareness among caregivers on the importance of vaccination - The survey found lack of knowledge among caregivers about, for example, the consequences of not immunising a child; on the other hand, the successes of immunisation programmes in Indonesia might also have been accompanied by the loss of fear of the diseases they protect against.
• Perception that vaccines are haram, or forbidden by Islam, in a Muslim-majority country.
• Distrust of government health service - There have been many examples of vaccine safety scares in recent years; in June 2016, vials marked as vaccines but filled with saline solution and antibiotics were discovered at 37 hospitals and clinics, and 23 people were arrested, including 3 doctors.
• Misunderstanding about adverse events following immunisation (AEFIs), including autism.

One slide shows the conceptual framework for routine immunisation, which is being used for the MR campaign with some modification. It outlines contextual variables, domains for communication interventions, initial outcomes, behavioural outcomes, and sustainable health outcomes.

In order to increase awareness among caregivers about MR, the campaign produced a number of communication outputs, engaging all the key participants' groups in the development (pretesting) process to get their feedback and input on:

• TV spots like this one; it is grounded in the Health Belief Model.
• Print communication materials such as a booklet, leaflet, banner, and poster designed to reach parents/caregivers, children/students, teachers, and the health cadre, as well as the public in general. In all of these materials, MR disease is clearly and consistently presented. Instead of saying, "Vaccinate your children", the materials say: "Protect your children from Measles and Rubella disease."
• Materials created through engagement with influencers and religious leaders to encourage parents and students for immunisation, disseminated through social media channels such as Facebook, Instagram, and WhatsApp, as well as the UNICEF youth engagement platform U-report.

During the second week of the campaign, almost 500 schools refused to participate. Some refused due to the halal/haram issue, and others refused because of lack of trust in government services. Mass media and social media news were also filled with content about the absence of halal certification of vaccines. The communication taskforce for MR worked with big religious organisations such as Nahdatul Ulama and Muhammadiyah to share Islamic views about immunisation. Pro vaccines alliances were formed during the mid-course of the campaign to counter not only the haram issue but also the anti-vaccine rumours and incorrect information about AEFIs. UNICEF, together with MOH, WHO, and the Ministry of Education worked with organisations such as Lions and the Rotary club to provide correct information about the MR campaign. The paediatric association is also very active in promoting the campaign through their members.

During the third-fourth week, CNN Indonesia TV published news of a young girl getting paralysed after received MR vaccination. Even though an investigation by an independent body revealed that it was not a case of AEFI, the news spread very quickly, also through social media, leading to some refusals and causing difficulties for some districts in achieving their target. The communication taskforce provided a recommendation to MOH to take immediate action by sending a warning letter to CNN and reporting names of those who are actively spreading rumours about immunisation to the police department.

A second public service accouncement, or PSA (see below), was developed and aired in September 2017 to specifically address issues about halal/haram, distrust of government services, and fear/misunderstanding about AEFI, as well as to encourage children/students, parents and children to go to the immunisation post to get MR vaccination.

As a result of these efforts, Indonesia successfully immunised 35 million children in Java Island, achieving 100% of its target. The campaign extended for 2 weeks to allow all districts to achieve the target of 95%.

A rapid convenience assessment (RCA) reveals that the main source of information about MR is mass media (61%) and social media (17%); the main source of mass media includes TV (95%). This result is consistent with findings from the U-report survey. Even though coverage is important, frequency is also crucial, according to Syafitri. People need to look at and listen to the materials several times so they can remember the message.

Lessons learned relate to:

• Coordination - With more than 100 districts involved, 240,000 schools, and more than 200,000 health centres and mobile health centres, coordination was a must. Technology has made communication and information sharing easier through communication platforms such as WhatsApp.
• Advocacy - This is crucial to secure national, provincial, and district buy-in for the campaign, particularly in countries like Indonesia with a decentralised government system. Direct outreach took place at the president's office in advance of the national launch to ensure high-level participation. The President himself launched the campaign, which sent a clear message to governor and mayors to make MR a priority.
• Partnership - UNICEF partnered with Jawa Pos, one of the leading newspaper agencies. In addition to amplifying messages about the importance of immunisation, Jawa Pos worked with UNICEF to approach governors and mayors. East Java province, which has a history of school and community refusal, managed to be the first province to achieve 95% universal coverage with Jawa Pos and UNICEF support. UNICEF is also working with the communication taskforce to partner with Rumah Ramah Rubella, a community with parents and children affected by rubella. This community has been very active in spreading information about the danger of the disease. UNICEF also partnered with the International Federation of Red Cross to specifically reach unregistered children such as out-of-school children and children who live on the street.
• Monitoring early detection of trouble spots using Rapid Pro - Rapid Pro, a short messaging service (SMS)-based platform, was used to collect data and provide real-time data feedback. This tool involves data management and a visualisation platform that facilitates real-time mapping and daily feedback of campaign progress. The system allows for the rapid identification of high-risk districts. The dashboard pointed to trouble-spots in comparatively well-off urban areas near Jakarta. What happened was that false rumors of side effects spread very quickly over social media. Parents were stopping their children from being immunised, and schools were closing their doors to teams of vaccinators. UNICEF was able to track these rumors through daily media monitoring of print, radio, and social media. It allowed communication for development (C4D) teams to work with government and respond quickly through direct outreach to parents, schools, and politicians, as well as through tailored media messaging. Senior management was able to support high-level advocacy with political and religious leaders - including with the president's office - directly.

Editor's note: The above is a summary of a presentation delivered by Rizky Ika Syafitri at Shifting Norms, Changing Behaviour, Amplifying Voice: What Works? The 2018 International Social and Behavior Change Communication (SBCC) Summit featuring Entertainment Education, held April 16-20 2018 in Nusa Dua, Indonesia.

Click here for the 25-slide PowerPoint presentation.