Welcome to Vol.10 of 'Behaviour Change Matters’. In this edition, we share how training frontline workers in interpersonal skills has helped boost routine immunization. The South Asia SBCC summit had interesting insights on gender and inclusion. 'Meet our Team' features Seema from our Hyderabad state office who brings management and entrepreneur skills to her work in SBCC.
We encourage sharing your experience and ideas on Social and Behaviour Change.
Sid Shrestha
Chief - C4D, UNICEF India
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BUILDING A 'BRIDGE' TO BOOST ROUTINE IMMUNIZATION
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Frontline workers ANM (1st Right) and ASHA (2nd Right) check on a 13-month-old child in Dungarpur district, Rajasthan, on their routine home visits. Representational image, © UNICEF India/2020/ Sri Kolari
A special training module developed by UNICEF has shown positive signs in terms of reducing awareness gaps and vaccine hesitancy in the community. Boosting Routine Immunization Demand Generation (BRIDGE) Inter Personal-Communication (IPC) is a training module developed for frontline workers (FLWs). This module was used in conducting a one day skills training of ASHA, ANM, and Anganwadi Workers across the country. Health workers form the most critical resource to achieve the routine immunization (RI) goal of reduced vaccine hesitancy and increased coverage. UNICEF began conducting a training of trainers in August 2017 across all states of India.
What is BRIDGE IPC module and how it works
The Boosting Routine Immunization Demand Generation (BRIDGE) IPC module is a special one day course designed to develop capacities of FLWs to leverage social and behavior change communication (SBCC) for routine immunization (RI). The suggested training content is largely based on the Tarang Training module endorsed by the Ministry of Health and Family Welfare (MOHFW) Government of India and developed by UNICEF on SBCC. BRIDGE focuses on improving inter-personal communication (IPC) skills of FLWs to improve RI demand generation and expansion.
The training was done in a cascading model. Lead Trainers at the national level underwent two-day training before the Training of Trainers (ToTs) at the state level. At the state level, District Trainers were selected by the states from their pool of health trainers while UNICEF state offices coordinated this selection. They underwent a one-and-a-half day residential ToT. The district trainers in turn did the day-long training for frontline workers in a phased manner across districts in the country 2018-2020. All FLWs in India were envisaged to be trained in two phases – Phase 1 comprising of 187 districts under the Intensified Mission Indradhanush (IMI), including the North-eastern states, and Phase 2 comprising of remaining districts in the country.
BRIDGE as a boost to frontline workers
Frontline functionaries play as an essential ‘bridge’ between the health delivery system and the community. The ASHA serves as the first point of contact for the community seeking information related to RI, especially in rural areas. The Anganwadi Worker ensures all mothers, pregnant women and children in the village visiting the anganwadi centre receive the services related to health and nutrition, including RI counselling. The ANM (Auxiliary Nurse Midwife) plays the dual role of being a vaccinator and primary counsellor to caregivers. The ASHA, Anganwadi Worker and ANM also collaborate for the monthly Village Health and Nutrition Day (VHND) in which RI is a key service.
However, recent studies showed awareness gaps and AEFI apprehensions as major barriers in improving full immunization coverage in the community. Hence the need for skill building of frontline workers to address these gaps has been observed. With the help of BRIDGE IPC module, FLWs develop the basic understanding of how to engage communities in issues regarding child health and immunization, deliver key messages and test understanding, self-assess results of their efforts, and engage with influencers.
Evaluation of the training
An evaluation of the training conducted by IPE Global in October 2021 covered five states: Uttar Pradesh, Rajasthan, Karnataka, Odisha and Assam. Overall, the BRIDGE IPC training was found relevant in strengthening the health workforce and service delivery. The findings showed that both district trainers and frontline workers found the training material, content, and methods appropriate and consistent towards delivering key messages on RI, mobilising communities, addressing vaccine hesitancy, preparing the village-level communication plan, and tracking vulnerable children.
Nearly 93% of the frontline workers reported that the IPC session was relevant to address the challenges they encounter while improving RI coverage. The top three methods preferred by the FLWs include videos/ films (65.0%), presentations (56.0%), and role-play (51.0%).
It was found that trained FLWs were more likely to target left out children through home visits (84.2%), community meetings (72.7%) and preparing lists of left out and dropout children (38.3%) than their untrained counterparts. Over 80% found the content useful, 63% said the training material was comprehensive. Observation at immunisation sites shows that most frontline workers followed the steps recommended in the training.
Overall impact on frontline functionaries
Post-training, a higher proportion of FLWs agreed that they felt confident (95%) and motivated (89%) while interacting with parents/caregivers on immunization. Close to three-fourths of the trained FLWs prepared the village communication plan (72.7%) which was higher than untrained FLWs (65.9%). This helped them identify the potential influencers in their area, key barriers such as low awareness on RI and the left out drop out and resistant families. The training positively influenced the targeting of vulnerable populations. The trained FLWs were able to bond with the community and more likely to identify and cover left out and resistant families.
The national level trainers say that the cascading model followed for implementing the training was useful to train a larger number of FLWs efficiently. However, though the BRIDGE module includes periodic refresher training, only one-third of the frontline workers received any refresher training. Other limitations include that half of them (50%) found the training content technical, and 26% found it generic and not contextualised as per their local needs. The long gap between training of trainers and training of frontline workers was also noted as a limitation.
NFHS 5 (National Family Health Survey 5, 2019-2021) data released in November 2021 shows that RI coverage has improved substantially: 76.4% of the children between the ages of 12-23 months received all basic vaccinations, up from 62% recorded in NFHS4 (2015-16). It also shows that 11out of 14 States/UTs have more than three-fourth of children aged 12-23 months with full immunization and the highest is for Odisha (90%).
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TRAINING WOMEN TO BECOME CREATORS OF THEIR OWN FUTURE
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All social change begins with a conversation. The recent South Asia SBCC (Social Behavior Change Communication) Conversation has led to new insights into women empowerment, transforming communities and promoting inclusion. The conversation was held as a virtual event between 7-9 December 2021, and brought together social and behavior change leaders, practitioners, planners and researchers to advance dialogue, inspire collaboration and spark innovation across intersecting focus areas. The event also highlighted the contribution of community media and the massive role it can play in order to transform women’s lives through content creation.
Creating conversations on radio
Farheen of Radio Mewat, Haryana gives voice to unheard stories and women’s issues through her microphone. “We address issues like domestic violence. We create conversations with women and girls about rights and empowerment,” she said. The radio jockey of the community radio station set up in 2021 was featured as part of the champions of social change in the spotlight section on day one of the event. She spoke about her work that empowers her and her community. She also narrated her own story of growing up in a village where boys were given preference over girls in every aspect of life. She had to drop out of regular school after Class 8th as it was not possible to go alone to a neighbouring village for school every day. Now, she goes to villages to do surveys and interviews lawyers and police officers. She helps women facing violence fight for justice and get counseling and legal redressal.
Archana Kapur, founder of Radio Mewat, believes that radio has proven to be a great medium to give women the voice they need. “When we train a young woman from the community, not only does it change her life, but she also becomes a role model for many. Farheen has today become the voice of the radio,” Kapur said. However, she feels it has been tough to train young women and girls from the community to work in radio given the patriarchal structure of the society and the taboo around girls speaking and being heard.
Getting new perspective through storytelling and filmmaking
Girls have used new-media tools such as films, radio shows and photo stories to influence community members to think about life issues from the female perspective. Day two of the South Asia SBCC Conversation focused on how storytelling through films can bring about a massive change and help reach multiple sections of the communities. A film on girls and young women trained by Feminist Approach to Technology (FAT) in camera work and videography was screened. FAT is a not‐for‐profit organization that trains girls to use tech skills to run a collective action in their own community.
Using the film "Todo Bandishen", 31 girl leaders ran a campaign against early and forced marriage in 2016. The film was screened in the communities they come from and reached over 10,000 people creating conversations on the subject. Older women reflected on their experiences of early marriage.
A member of FAT said that their aim is not just to make a film but create a campaign around the issue. Girls who were trained in filmmaking said being part of the FAT training helped them understand the subject of early marriage. “I learnt about rights, I didn’t even know girls have rights,” one participant said. All the young women expressed how being involved with this gave them tremendous confidence, some even said it gave them a sense of identity and respect in their communities.
Commenting on the film, Priyanka Dutt of BBC Media Action said, “This just shows the transforming effect of learning technology. It’s not just access to education, which is fundamental, literacy is about technical learning, it is learning about the world around us, how society around us is constructed and what our role in it is. It is giving girls the tools to negotiate powerfully with those who create boundaries in their world.”
Uttara Bharat Kumar of John Hopkins Center for Communication Programs said power dynamics are always going to be there, “changing social norms – what is and isn’t acceptable– is an important first step.”
Nirmalya Mukherjee of NGO Mant spoke about a study done in Purulia, West Bengal, on health communication targeted at tribal women. The study found that training tribal women with skills to create media led to more effective communication materials for their community. “Tribal communities have their own distinct culture and language. These are media dark areas. We run a community radio programme here. We further trained women who work in community radio to create media content on handwashing and sanitation.” The NGO trained the women in how to use technology, gave them skills such as editing, creating videos and taking photographs.“ At the NGO level we don’t have a role in content creation, the tribal women do that on their own,” Mukherjee said. The study found that community ownership led to more effective messaging. As tribal women used different formats such as phone-ins and storytelling, they were able to engage the community effectively.
The South Asia SBCC Conversation was hosted by a consortium of global partners including the BBC Media Action, Breakthrough, Centre for Communication and Change-India (CCC-I), Johns Hopkins Center for Communication Programs and UNICEF India, supported by a network of organizations and partners in the India SBCC Alliance.
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MEET OUR TEAM: FROM MANAGEMENT SCHOOL TO SOCIAL SECTOR -- SEEMA KUMAR, C4D SPECIALIST
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Seema’s journey with UNICEF began in 2004 from the Guwahati field office as part of the C4D team. Over the years she has worked with various state offices of Uttar Pradesh, Bihar and is now based in Hyderabad.
While growing up in Lucknow, Seema was interested in business and finance. “I wanted to be an entrepreneur,” says Seema. She was always clear in her mind about being financially independent as early as possible. However, it was while studying management that she developed an interest in the social sector. A job with SIFPSA, the USAID funded programme for family welfare in Uttar Pradesh helped her learn about strategic communication and social marketing.
At the UNICEF office in Lucknow, Seema has been the co-coordinator for the 5,000 strong Social Mobilization Network (SMNet) for polio in Uttar Pradesh. “It feels good to know that the work we did contributed to polio eradication in India,” Seema says. Over the 10 years she has been in Hyderabad, she recounts setting up institutional mechanisms for social and behavior change in the three states she works in -- Andhra Pradesh, Telangana and Karnataka -- as a major achievement.
Seema recently completed 14 years of motherhood and the journey has been extremely rewarding. Apart from her daughter and partner, her family comprises her parents “who uprooted themselves” to move with her over the years and have been a pillar of support. Their pet dog Luna adds joy and energy to the household. In her spare time, Seema loves to be with the elderly. She used to volunteer at an elderly persons' care facility in Lucknow and plans to resume it in future. Seema loves to write poetry and short stories in Hindi and also maintains a gratitude journal.
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CoVLEx Initiative Launch Report: In September, 2021, the Ministry of Health and Family Welfare (MoHFW), USAID/India, and the NITI Aayog, Government of India (GoI) officially launched the USAID-supported City-to-City COVID-19 Vaccination Learning Exchange (CoVLEx) initiative. This initiative aims to fill the vaccine knowledge gap by bringing together donors, governments, development organizations, academia and the private sector from Asia and Africa to offer valuable insights around COVID-19 vaccination.
Understanding Intersecting Vulnerabilities Experienced by Religious Minorities Living in Poverty in the Shadows of Covid-19: Study in India and Nigeria by IDS (Institute of Development Studies) and CREID (Coalition for Religious Equality and Inclusive Development), UK, Joanna Howard et al, October 2021.
75 Years of UNICEF: Established in December 1946 in the aftermath of World War II, UNICEF has been at the frontlines of humanitarian crises, armed conflict and natural disasters. Its on-the-ground expertise has reached more than 191 countries and territories through committed partnerships and a passion for innovation.
ABBA's Little Things: Proceeds from ABBA's new Christmas song Little Things will be donated to UNICEF's global work to protect children, especially girls, from violence.
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