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1 AUGUST 2022
Welcome to Vol. 17 of ‘Behaviour Change Matters’. With most of the humanitarian effort aimed at fighting the COVID-19 pandemic, Routine Immunization has faced a severe low in past two years around the world. In this edition, we look at how pacing up immunization is the need of the hour to create a healthy tomorrow for children. While the IMI 4.0 campaign in Madhya Pradesh has reached more than a million people through its mobile van intervention, we also see how using solar energy in a small Jharkhand village leads to remarkable improvement in vaccine reach and disease prevention. In Dantewada district of Chhattisgarh, teachers play the role of vaccine advocates, and our Meet the Team piece is about women power from Bihar office where Mona and Soniya share the secret of what keeps a strong team together under the challenges of development programming.  
Sid Shrestha Chief - Social and Behaviour Change, UNICEF India

Intensified Mission Indradhanush 4.0 accelerates Routine Immunization in 10 districts of Madhya Pradesh, covering 5879 strategic locations with a reach of more than one million, catching up on the gaps created due to COVID-19 pandemic

IMI 4.0 campaign showed that cross-sectoral participation can lead to remarkable increase in the vaccination rate amongst children. It covered 10 districts of Madhya Pradesh, with a total reach of 14,65,441 persons. ©UNICEF/India/2022

Located on the centre of India’s map, Madhya Pradesh literally means the ‘central province’. It is the second largest state in the country in terms of area, with a population of over 72 million. World renowned for its cultural heritage as well as the natural environment, the state boasts of stunning tourist destinations and picturesque locations. More than 21 percent of the state’s population is made of Scheduled Tribes, 46 of which are recognised and three of them have been identified as Particularly Vulnerable Tribal Groups (PTGs).

Madhya Pradesh has a number of health challenges in terms of malnutrition, infant mortality rate and infectious diseases. Keeping such challenges in mind, the Intensified Mission Indradhanush (IMI) 4.0 was launched by the Government of India in February 2022 with the aim to identify and reach the unvaccinated and partially vaccinated children and pregnant women in 11 Indian states including Madhya Pradesh.

In the recent times, the fear of COVID-19 infection at the immunization sites emerged as a major barrier for many parents, caregivers and beneficiaries to opt for not availing Routine Immunization (RI) services. The lockdown disrupted the RI services and also diminished trust and confidence in the health system, increasing stigma, and reducing vaccine confidence in the community that further complicated the immunization coverage. Consequently, there was a major gap in the coverage of RI services, leaving children vulnerable to diseases.

To catch up on the gaps created by the COVID-19 pandemic in 2020-21, IMI 4.0 is also working on building community engagement channels with UNICEF support, in order to reach the targeted children and women around the country. The rounds of IMI 4.0 were conducted in 10 identified districts of Madhya Pradesh between March to June 2022 that reached more than one million people of the state, including children and pregnant women.

Reaching the unreached

Launched on the 7th of March 2022, IMI 4.0 has helped pace up the immunization of pregnant women and children in Madhya Pradesh. In a new initiative, the National Health Mission (NHM) officials have used mobile vans to reach out to the people living in the interiors of the state with a mission slogan- 'Hum Pahuchein Un Tak, Jo Na Pahuchein Hum Tak' (we reach the ones who cannot reach us).

IMI 4.0 covered 10 underperforming districts- Sagar, Mandla, Jabalpur, Satna, Seoni, Chhindwara, Morena, Damoh, Gwalior and Datia where vaccination coverage ranges from 76 to 83. Under IMI 4.0, vaccines are administered to protect children against 12 major diseases and the objective is to cover all those children who are either unvaccinated or are partially vaccinated against vaccine-preventable diseases. The 10 IMI districts include some of the most remote and difficult to reach areas of the state.

Community reach through mobile vans

To reach the communities with immunization messages, engage with them and motivate them to come forward for immunization, 10 multi-media vehicles or IMI Raths (IMI carts) were run with route charts (one vehicle each) in each IMI targeted district. The vehicles were equipped with AV & PA facilities, branded with the campaign’s theme and logo and accompanied by facilitators to help people seeking advice. Two state-specific mascots, Chacha Samajhdar (uncle wise) and Chachi Samjhadar (aunt wise) already popular during the COVID times, were also used to promote the key messages with a selfie point for the selfie contest to generate public interest. Audio-visual messages were displayed on the TV screen present in each of the multi media vans and distribution of leaflets and games amongst the parents and children was organised. “The van brings in the crowds in the village. It helps attract people with the medium of games like snakes and ladders and various quizzes that the children enjoy. At the same time it helps us in giving immunization messages to them and their parents”, said Meera Yadav, ASHA worker, Seohra block, Datia district.

There was multiple monitoring of the vans, by the district administration, health officials and also UNICEF’s partner NGOs. GPS trackers were also used to keep an account of the area covered by the vehicles. During vaccination rounds, daily supervisor meetings reviewed the available data and discussed the problems and solutions.

Making way through communication

The health department of Madhya Pradesh worked intensively to build the momentum for the IMI 4.0 campaign to regain the lost opportunities for vaccinating children during the COVID period. The frontline trio of ASHAs, ANMs and Anganwadi workers supported the entire community mobilization process through community meeting and house to house visits using inter-personal communication. UNICEF partners in the districts worked with the health teams to mobilise and motivate communities, especially in the low coverage areas.

Anganwadi Workers like Urmila Rajput believe that such campaigns could help lead to a bigger change in rural areas in the long run. “We need such vans to mobilise people not only during IMI but also during regular times to bring people especially from remote areas to come forward for immunization,” she said.

According to Jhimly Baruah, SBC Specialist, UNICEF Bhopal, the USP of this intervention is the accountability of the vans. “During my monitoring of IMI and this intervention, the District Immunization official and teams appreciated this intervention which supported in mobilizing communities and especially left out and dropouts in remote areas to come for immunization.”

A positive outcome

IMI 4.0 campaign showed that cross-sectoral participation can lead to remarkable increase in the vaccination rate amongst children. It covered 5879 strategic locations as per the route charts, with a total reach of 14,65,441 persons. This includes 4,59,134 women and 5,45,187 children from 10 districts of Madhya Pradesh.

WHO and UNICEF have recently recorded the largest sustained decline in childhood vaccinations in approximately 30 years around the world. 25 million children missed out on one or more doses of diphtheria, tetanus and pertussis (DTP3) through Routine Immunization services in 2021 alone. Monumental efforts are required to reach universal levels of coverage and to prevent outbreaks. Government of India has identified and vaccinated 4.36 million children and 1.1 million pregnant women till now through its flagship Mission Indradhanush programme. 

Teachers in Dantewada district of Chhattisgarh help fill in literacy related gaps leading to positive influence and improved vaccination records in the region

Bastar Samajik Jan Vikas Samiti (BSJVS), supported by Alliance on Immunization for Health (AIH), has been driving the Routine Immunization programme for children under two years in 24 villages across Bastar, Chhattisgarh. The efforts to achieve full immunization coverage by expanding outreach to left out, drop out and resistant families in the villages of Bastar has faced many hurdles, but none bigger than vaccine hesitancy – a result of poor literacy rates and lack of awareness in the area. In the following story, we witness how teachers play the role of educators as well as influencers to help combat the challenge of low immunization rate in the region.

When solutions come with challenges

As a traditional practice, Teeka Sakhi (vaccination friend) volunteers in Dantewada have been referring to the due list containing beneficiary details available with the ASHA, Anganwadi and ANM workers in order to reach out to the community members for Routine Immunization. However, through house visits and community interactions, it became apparent that not all families found themselves in these due lists. In order to fill these gaps and truly ‘leave no one behind’, a child tracking system was established across all the targeted villages. The system, to be maintained by Teeka Sakhis, obtained a live due list at the beginning of each month through direct interaction with the community. This list was then checked against the due lists available with the ASHA, Anganwadi and ANM workers, and observed gaps were filled in. Doing this at the start of each month gave Teeka Sakhis enough time to convince the hesitant families. The challenge, however, was the maintenance of databases. It was observed that the Teeka Sakhis, some of whom were semi-literate, were seeking help of their children or any other literate person in the village to fill and maintain the records in the database, which did not seem like a sustainable arrangement. 

From education to immunization – teachers lead the way

It was observed that apart from being literate, the teachers of local schools were respected by the community and had the power to positively influence people. Initially engaged to support the regular updating of the child tracking system, the teachers then started expressing interest in being more actively involved in social mobilization efforts.

During the World Handwashing Week, teachers of Dantewada district led a series of demonstrations disseminating key messages on the importance of washing hands to keep diseases at bay. ©UNICEF/India/2021/RuhaniKaur

Soon after, the teachers were inducted into a training programme on Routine Immunization, COVID-19 precautions and hand washing. During the World Handwashing Week, teachers led a series of demonstrations disseminating key messages on the importance of washing hands with soap to curb the pandemic and keep other diseases at bay. They also held special awareness sessions with parents and used the parent-teacher meeting platform to speak on the importance of practicing COVID-19 Appropriate Behaviours (CAB) and availing the COVID-19 vaccine, as well as included a special weekly class on immunization in the school syllabus. In some villages of Dantewada, teachers took the initiative to refer converted families to Village Health and Nutrition Day (VHND) session sites, thereby becoming vaccine advocates and driving change from within. Thanks to the efforts of the teachers, immunization rates in Dantewada have improved remarkably. Everyone in the village – from the elderly to the school children – appreciated the important role they have been playing in spreading health awareness.

Vaccine advocates, in the classroom and beyond

Lila Sori, a teacher in village Koriras in Dantewada, said: “This new role of a social mobilizer is exciting and gives me the opportunity to do more as a teacher. I will always cherish this experience.” As teachers became a vital part of social mobilization efforts in Dantewada, the news of this successful strategy spread far and wide. District Bijapur followed suit and included teachers in their COVID-19 and immunization campaigns. Soon, other districts will follow.
Using solar energy in a small Jharkhand village leads to remarkable improvement in vaccine reach and Routine Immunization

Located on the Giridh plateau region of Jharkhand, Pirtand is a small community development block spread over about 400 square kilometres of area. The district is heavily forested with a population of 109,515, almost all of which are tribal, rural, mostly earning a livelihood through agricultural labour or household industry work. Although there are 194 inhabited villages in the Pirtand, the block is still listed as a backward region and seems far from the infrastructural plans of the local government. While lack of proper roads makes it difficult for the ill to reach the local health care centres, it is equally challenging for the health care workers to reach out to the people in need. During monsoon, the health workers even walk for 4 to 5 kilometres everyday, crossing a difficult terrain by foot in order to reach people with medicines and basic health care facilities. Under such circumstances, a unique initiative by UNICEF has proved to be a ground breaking step towards improving immunization in two of the far-flung health care centres of the region.

Harladih and Kudko villages are about 25-30 kms away from the district headquarters of the region. Being on the outskirts of the block, the health care centres in both villages regularly faced limited amenities especially in terms of the provision of vaccines for the women and children of the community. It would take an hour long drive for the vaccines to reach these centres from the block cold chain point. The distance and lack of proper vaccine storage facility would lead to delayed delivery of vaccines to session site leading to missed opportunities of immunizing children.

As a UNICEF initiative, a solar panel was set up at the Harladih health care centre to combat the problems faced due to power shortage in the region. ©UNICEF/India/2022

UNICEF advocated with the district health department to set up a cold chain point in the area at Harladih health and wellness centre to reduce travel time of vaccine and accelerate the process of immunization. Vaccine cold chain is a network of cold rooms, freezers, refrigerators, cold boxes, and carriers that keep vaccines at the right temperature during each link on the long journey from the manufacturing line to the syringe. It was important to establish a system that could support the vaccines to be transported, stored and be used as per the requirements in these two areas. However, a bigger hurdle was lack of electricity to run any such system as shortage of power was a major issue faced by the region during monsoon.

The solar deep freezer helped establish a cold chain system that further supported 40 AWCs in the vaccination process in Giridh district, Jharkhand. ©UNICEF/India/2022

With the help of Solar Direct Drive cold chain equipment supplied by UNICEF to the Harladih health and wellness centre, it could now store the vaccines despite power shortage and distance from the block headquarters. A solar freezer or refrigerator works with a solar panel and a battery bank. The solar panels absorb energy from the sun and supplies energy to cold chain equipment.

Dr. Vanesh Mathur, Health Officer, UNICEF Ranchi said, “Now with cold chain point in the remote Harladih which runs on solar energy, the time taken for vaccine delivery has reduced significantly which has led to increased time for vaccination, better vaccine  and cold chain management. This would result in better immunization coverage.”

73% of the frontline workers in the target region underwent the BRIDGE (Boosting RI Demand Generation) Interpersonal training that helped develop their skills towards Routine Immunization. ©UNICEF/India/2022

In addition to strengthening the supply chain for vaccines, UNICEF worked closely with the government in order to inform and engage the local community and generate demand for immunization services. UNICEF supported the local authorities to build interpersonal communication skills of the AAA (Asha, Anganwadi and ANM) workers. 73 percent of the frontline workers in the region underwent the BRIDGE (Boosting Routine Immunization Demand Generation) training. BRIDGE IPC module is a special one-day course designed to develop capacities of frontline workers to leverage SBCC for Routine Immunization. UNICEF also developed communication materials on immunization in three tribal languages which are being used by NGO partners and social mobilisers to promote immunization and ensure vaccination for the left out, dropout and resistant communities.

The green cold chain system in Harladih came as a big relief for the local health workers. As a result, 40 Anganwadi Centres in the area are able to provide immunization for the women and children of the local communities.
Coming from two different professional backgrounds, when Mona Sinha and Soniya Menon’s paths met at UNICEF, they got the best of two worlds to make a strong and versatile team for Social Behaviour Change in the UNICEF Bihar office. Mona started her journey in the world of Indian cinema with the acclaimed filmmaker Prakash Jha and learned the importance of discipline along with creativity. With a Masters in English Literature, she is also qualified in Hindustani Classical music. Soniya’s first job was with the Indian Institute of Forest Management – her first step into the development sector after completing her two Masters degrees, one in human resource management and the other in social work. A firm believer in academics, Soniya also has an MPhil. from Public Health Foundation India to her name. After joining forces for almost four years together at UNICEF Patna office, Mona and Soniya form the backbone of UNICEF’s SBC operations in Bihar.
Mona’s vast experience helps develop system strengthening, advocacy and partnerships, formulation and implementation of SBC strategies and campaigns, as well as gender related initiatives at both the state and national level. On the other hand, having been a part of a successful Polio intervention in India, Soniya comes with immense understanding of holistic child development along with components like Routine Immunization, WASH and Nutrition. Due to her intensive engagement with the Polio Programme, Soniya is able to easily apply various approaches to the current interventions.

Ask them what keeps them together as a team and they both believe it’s the healthy and friendly work environment that enables them to give better results. “We both come with our own strengths and weaknesses and complement each other well. We always seek each other’s advice and do not shy away from friendly and sometimes constructive arguments also. But at the end of the day, we both work for the common goal and trust each other. We are the best critiques of each other,” says Mona.

Soniya believes that understanding each other’s point of view as well as the ability to perform under various circumstances has helped them both develop a friendly and trustful work relationship. “We both come from different disciplines of study and bodies of work, thus bearing multiple perspectives and interests. This diversity in our team helps us flourish more and make a lasting impact. Each of us are accountable for our own key result area, which gives us the required space to perform and excel at our own pace, which I feel is the biggest plus factor in our current working relationship,” she says.

Currently, Mona works as the Social and Behavior Change Specialist, while Soniya is the SBC Officer for programme section. Mona and Soniya feel that UNICEF is a great platform for youth that provides a vision and opportunity to bring about change at a bigger level. After spending almost 14 years as part of the UNICEF family, Soniya says, “My UNICEF journey has been very rewarding and transformative. I am fortunate to be a part of an organization that strives to make the difference in the life of every child on this planet. It has now become more of my mission and vision, rather than a job that I was hired to do.”  

Mona feels that the recognition you get for your accomplishments at UNICEF is one of the most important aspects of this profession. “This is the place to come to in the development sector for a rewarding career and huge learning opportunities. It opens the gates for opportunities in other organizations, builds skills in working with government bodies and gives satisfaction in terms of getting results for children,” she says with firm belief. 

In her free time Soniya likes to travel, read, cook and bake for her family. Mona being a cinema lover at heart likes to spend time watching films and documentaries, listening to music and sketching.
The documents disseminated by Behaviour Change Matters
do not necessarily reflect an official position by UNICEF.

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