2 MAY 2022

Volunteering is an act of heroism in a way; it does more than helping people beat the odds – as it changes the odds. Teeka Sakhis or vaccination volunteers in India are using innovative social mobilization approaches to spark inspiring conversations among mothers. “Teeka” in Hindi means vaccine and “sakhi” refers to a female friend. Thus, these unique volunteers play friends and bring about the most needed change for their communities. This has led to a ground level, large scale intervention towards improving the statistics of Routine Immunization in many parts of rural India. UNICEF along with partners came across remarkable stories of many such Teeka Sakhis who changed minds and transformed behaviours with their hard work and consistency.  
 
 
Building trust

                 
Teeka Sakhi Soha Kumari would discuss financial issues with mothers, followed by vaccination advice. ©UNICEF/India/2021-22 

Soha Kumari, a 29-year-old Teeka Sakhi and a mother of three children, has proven herself as a changemaker in her ward in Gaya, Bihar. An effective communicator, she is able to expertly navigate difficult conversations with caregivers on vaccines and allay their apprehensions about them. But when it came to a reluctant mother of a newborn unwilling to talk about vaccines, Soha decided to adopt a different approach.
 
During a routine visit to Priyanka’s house, Soha did not bring up immunization. Instead, she discussed financial issues that she knew were a priority for Priyanka and invited her to a self-help group (SHG) meeting for further deliberation. At the meeting, several development and financial literacy topics were discussed at length. Soha opened the floor for a discussion on immunization as the last agenda for the day, assuring the caregivers that this was a safe place to discuss all their vaccine-related woes. A few mothers started off by confiding about their worries, many more began to speak up. Under Soha’s able guidance, these mothers shared their own experiences of overcoming doubt and fear to act in the interest of their children’s health. Soha discussed the benefits of vaccines in with the help of pictures, posters, and informational handouts for the mothers to carry home.
 
The following week, Soha escorted the family to the immunization session site and spent the day with Priyanka and the baby to reassure her and allay any apprehensions the family may have had.  
 
Different strokes for different folks
 
Shobha Devi, a young mother of two children and a dedicated Teeka Sakhi understands that not all issues need to be tackled head-on especially when it comes to creating awareness on a sensitive issue like immunization. Shobha observed that Narmada and Laxmikanth, a couple in her community had negative views on immunization, although in varying degrees. While Narmada could be described as reluctant, Laxmikanth was vehemently opposed to the idea. Far from entertaining a conversation on the topic, he would become extremely angry with Narmada for broaching the subject.
 
Through her various home visits, Shobha realized that while Narmada could be convinced, Laxmikanth would need more persuasion in this matter. Shobha adopted a unique strategy in order to counsel the couple. She first made sure that she would visit their home only when both were available. However, her conversations and message delivery was towards Narmada, making sure that Laxmikanth was also listening. During these conversations, she would go into painstaking detail about the various illnesses that could afflict their child, citing examples from her own experiences. In the end, she would emphasize how these diseases could easily be prevented by vaccines, leaving them with this thought to ponder over.
 
After several visits, Shobha started observing a change in Laxmikanth’s attitude. And then one day, during another routine visit, Shobha met with an elated Narmada. Laxmikanth had finally relented and agreed to vaccinate their child. They decided to meet the following day to go over the immunization schedule.
 
Conviction is key
 
Sangeeta Kumari, another young Teeka Sakhi from Gaya district in Bihar, is known for her perseverance in convincing parents. Her assertive style and relentless spirit accord her immense respect in her community. People look up to Sangeeta and trust her when it comes to deciding upon the interest of their children’s health. However, some families need a little more convincing than others.
 
              
         Teeka Sakhi Sangeeta took the responsibilty of any risk associated with the vaccination of children in her community and                   accompanied them to the health centre. ©UNICEF/India/2021-22

In one such incident, Sangeeta’s skills were put to the test when she was tasked with convincing an extended family of three mothers to vaccinate their newborns. The family’s reluctance stemmed from an unfortunate event that occurred years ago. A child they knew passed away only a few days after receiving a vaccine, although there was no evidence to suggest that the vaccination had anything to do with the child's death. But after the incident, the mothers resolved never to vaccinate their own children.
 
On one of her routine visits to the family, Sangeeta found that one of the newborns was suffering from diarrhoea.  Thereafter, she spent the whole day educating the mothers about the benefits of vaccines, explaining how diarrhoea is one of the most common causes of other illnesses and death in children under the age of five, and there are vaccines to protect us from it. After hours of convincing and explanations, all the mothers agreed to get their children immunized, but on one condition: if anything happened to them, Sangeeta would be held responsible. Calm and confident, Sangeeta readily accepted, asserting that the community’s children were her responsibility anyway, and she would let no harm come to them.
 
As the health of the newborn suffering from diarrhoea improved over the next few days, Sangeeta accompanied the mothers to the immunization site, where all three children were inoculated with their first doses. The mothers kept in touch with Sangeeta and continued to return for subsequent vaccine shots.  

“Our Community Led Model is an Example for the World”

 

The Alliance for Immunization& Health (AIH), UNICEF's partner in the Indian state of Bihar has been working with communities in two of the state's districts- Gaya and Purnia, to improve the Routine Immunization coverage for children. Brijesh Kumar, AIH's Bihar State Coordinator, has been championing these efforts through a system-driven, outcome-focused approach. Enroute to Gaya, we caught up with Brijesh to learn more about his perspectives on the programme, behind-the-scenes efforts, and the challenges that his team faced.

 

How did the effort to boost Routine Immunization (RI) begin, and how was the overall project structured?
 
We observed that Bihar’s Gaya and Purnia districts were characterised by pockets with high reluctance and immunization hesitancy. There were also several dropout cases reported in these areas. UNICEF tasked AIH with transforming and boosting the Routine Immunization coverage in these areas. We wanted this to be a bottom-up, community-led, and community-driven programme. Hence, we devised a detailed, three-phase strategy for the programme that included identification and training (Phase 1); implementation (Phase 2); and stabilisation and scale-up (Phase 3).
 
Can you elaborate on the identification and training part and the focus activities that took place during the programme?
 
The primary aim of the first phase centered on identifying focus blocks and villages in the district, and conducting training within each of them. We consulted the local administration for this purpose, as working in silos is a futile exercise. We conducted extensive meetings and brainstorming sessions with the State Immunization Officer, and subsequently with the District Immunization Officers (DIOs) of both districts. We were made aware that though the basic health infrastructure was in place, there was a gap of 15-20% in Routine Immunization coverage in many areas. We were mandated to plug this gap. We identified prominent self-help groups (SHGs) in every village to help with our project. Women within the community were identified and nominated as vaccine promotion volunteers known as Teeka Sakhis (vaccine-friends) for this purpose. Several rounds of well-designed workshops were conducted as experts from UNICEF, WHO and the Government were brought in for a few sessions, as well. In a nutshell, Phase 1 was identifying the focus areas and creating a frontline, community-led, and well-trained immunization workforce.

What were the different challenges you faced while creating the frontline work force and how did you manage to overcome them?

Our primary task involved filtering the long list of SHGs, using ground intelligence and field visits to verify which SHGs were active and could potentially be utilised for our project. It took us 20-30 days to complete this task. We also consulted local leaders for their suggestions regarding SHGs. This served a dual purpose for us: identifying the SHGs and ensuring buy-in from local leaders. The second challenge we faced was reluctance among many proactive SHG women about joining us as Teeka Sakhis. The reasons were varied, but the most common reason was that they had household work, needed to take care of their children, get their husbands’ permission, etc. Here, we must also note that we do not compensate the Teeka Sakhis monetarily. It is a volunteer activity. However, I am happy to say that in these two Bihar districts, we successfully enrolled more than 350 women (mostly mothers) and trained them to become effective changemakers.

What motivated the Teeka Sakhis to join the programme and work consistently without any financial incentive?

                                                
  Teeka Sakhi volunteers have touched the lives of more than 2000 children in the state of Bihar. ©UNICEF/India/2022

We made regular efforts to make these women realise that being a part of this effort was beneficial—not only to their children, but the entire community. Many women were inspired by the fact that they could play a role in shaping a healthier society. Moreover, several intangible benefits arose from being a part of the Teeka Sakhi programme. Women realised it increased their self-confidence and soft skills, such as speaking in public forums. It also gave them an opportunity to meet new people and make new friendships. We also conceived of a “reward and recognise” scheme that identified the best-performing Teeka Sakhis and rewarded them with certificates and awards.

As we are nearing the end of the programme, how do you feel about its achievements?
 
I am proud of the fact that this model has worked. Our community-led model is an example to the world for how social and behavioral change can be shaped from inside the community itself. All it requires is planning, patience, and passion! We have touched the lives of 5,000 families, and more than 2,000 children can have healthier lives. The entire health system from the bottom up is happy with the fact that we could convince so many families to get their children vaccinated. Beyond vaccination, our Teeka Sakhis have become model changemakers in their local communities, confident and able to take up other social issues— slowly creating change in society.  

                                               
Sometimes all it takes is for one person to put up their hand, take responsibility and nudge society towards change for the better. Imran Hussain, a farmer from Mundi Milak village in District Moradabad of the north Indian state of Uttar Pradesh decided to lead from the front when it came to the welfare of his community. Imran observed that his village and surrounding communities had been living in doubts and apprehensions        associated with health services for decades. Routine Immunization for the prevention of life threatening infectious diseases amongst children had taken a back seat in the area. People harboured all kinds of misconceptions about vaccines. Some said they lead to infertility, while many believed that immunization could make you ill for life.

Man with a mission

A respected member in his community and fondly known as Imran ‘Bhai’ (Brother Imran) by everyone in the village, Imran felt strongly about the benefits of vaccination. He collaborated with the local ration dealer and trained him on informing the mothers of young children about the benefits of vaccination while rations were distributed. On a few occasions, he distributed free rice and wheat to those coming forward to vaccinate their children. Imran started with direct and positive ways of communication to mobilize his community, particularly the left out, dropped out, and resistant (LODOR) families, for vaccination. However, these efforts led to a marginal change in perception towards immunization. Imran wanted to go one step further and he decided to adopt a personalized approach in order to address his community’s worries with the aim of further improvement in the uptake of vaccines. This time around he sought the help of the District Coordinator of Alliance for Immunization and Health (AIH) – a UNICEF     partner working to improve immunization coverage in India, and set out on a mission. He began visiting reluctant families door to door, educating them on the benefits of immunization, often bringing along doctors and other medical staff from neighboring cities to make an evidence-based case.

Power of perseverance

Shahana and Dilshad, a couple in the community, were especially opposed to vaccinating their second son, Hasan. The hesitancy was triggered by the trauma of losing their first son to illness who coincidentally had passed away soon after receiving his first dose of a vaccine. Although doctors confirmed there was no evidence to suggest vaccination as the cause of death, the parents could not be convinced to vaccinate their second child. Shahana and Dilshad refused to step out of their house when health officials came on vaccination rounds. In terms of immunization, the second son Hasan was a ‘dropout’, which meant that his vaccination had never been completed. He was inoculated at birth but never received the subsequent doses. Imran visited Hasan and subtly nudged the parents. Aware of Shahana and Dilshad’s tragedy, he refrained from pushing them too much. He did, however, educate them about the safety of vaccines with help from the AIH District Coordinator. Slowly but surely, Imran won the family’s trust. He took responsibility for ensuring Hasan’s safety and listed his name on the vaccination schedule. Hasan is now a fully vaccinated and healthy child.

                      
               Thauseef Alam, a cousin of Imran’s, ensured that all of his children were vaccinated. ©UNICEF/India/2022

As successful as these community efforts were proving to be, Imran ascertained that the impact would be more significant if he cultivated other influencers in the community. He first identified a number of vaccine-hesitant relatives and friends and spent a few weeks educating them on the importance of immunization. They agreed and soon started vaccinating their children. Once these folks realized that none of the alleged side effects had occurred, Imran urged them to convince their neighbors to vaccinate their children. A multiplier effect had begun and soon more than 25 children in the village were vaccinated.
 

Championing the cause
 

Maulana Farman Ali, a local maulvi (Islamic preacher) heard about Imran’s efforts and approached him to request support in increasing awareness about childhood vaccination among his congregation. The members of this congregation were hesitant to embrace vaccines as they felt maladies should be healed by God or by natural means.Together, Maulana Farman and Imran made regular announcements after daily prayers to address congregants’ apprehensions.  Through  the  weekly sermon after the Friday prayers, they motivated people to avail vaccines by quoting relevant lines from the Quran (holy book of Islam) that emphasize caring for the health and wellbeing of one’s own self and community. By leveraging their standing among their people and weaving the message of immunization into religious preaching, Maulana Farman and Imran are catalysing social and behavioral change and championing the cause of Routine Immunization. Imran continues to be a beacon of hope for his community.
 

A passionate social sector manager and an expert in the area of Social and Behaviour Change Communication for child health, survival and development – Bhai Shelly has more than 30 years of experience in the humanitarian world. Born in Daltonganj, Palamau, a small place in South Bihar then, now part of Jharkhand, Bhai was the fifth child among six siblings. He holds a Bachelor’s degree in Economics from Patna University after which he moved to New Delhi to study at the Indian Institute of Mass Communication. As an observant young boy, Bhai realised that every stopover in life was an opportunity to learn and make decisions about the path he wanted to take. “As a child, I travelled extensively in rural Bihar and witnessed the social-economic misery of common people. My aspirations evolved as I grew up and saw more of the world around. Firstly, being a civil servant as profession looked close to what I aspired. I gradually got attracted towards media and social development.” Bhai started working as an intern with the Hindustan Times daily newspaper and he started writing extensively on developmental issues in the country for various other publications. However, getting associated with Swami Agnivesh-led campaign on bonded and child labour proved to be the turning point in his life. This was the formal kick start of Bhai’s career in the social sector that took him back to the state of Bihar and then to Uttar Pradesh. 
                                   

 
Bhai believes that in communication it is important to keep the audience first. This helped him design several impactful people-centered media campaigns and he eventually joined UNICEF as lead consultant for Social Mobilization, Polio Eradication in 1999. That was the time when UNICEF and WHO did a joint fact-finding and gathered evidences around behavioural and social bottlenecks together. Bhai feels that Polio eradication in India has been one of the most satisfying experiences in is career. The second high point for him was work around Social Capital strategy where Bhai’s special responsibility within the Polio Network was capacity development as they trained almost 5000 community based mobilizers and their managers on monthly basis.  
 
After more than two decades with UNICEF, Bhai believes that working here has groomed him both as a professional as well as a person. “I acknowledge my gratitude and solidarity for three reasons. One, it allows us to dream big, experiment and fail. Two, it makes decision in the best interest of the children. And the third, but not the last reason is its respect for diversity and inclusion.”

Today, Bhai Shelly leads Social and Behaviour Change unit in UNICEF’s Uttar Pradesh office, India. He is married to Kamlesh Rathore, an IIMC alumni and writer. They have a daughter Aarohi Surya who is a marketing professional in Dubai. He likes spending time with his family, singing and writing short stories and poems in his spare time. A travel-lover who loves both hills and beaches equally, Bhai also likes listening to Sufi music and Kishore Kumar songs.