1. Social Mobilization Strategy for Routine Immunization in Bihar –
“More than just posters”
Background and Introduction
The routine immunization system in Bihar needs strengthening. Much remains
to be done if the impact of immunization on the health of the child is to be
realized. More than half of the children who begin their immunization seriesdrop
out before completion due to problems in supplies reaching the delivery points,
awareness, demand and quality of services. Compounding this is poor
infrastructure in relation to manpower and lack of training on clinical as well as
managerial and communication / mobilization skills that lead to infants not
receiving the vaccination as per schedule. Added to these is the lack of accurate
routine data to identify problems and target contextually appropriate solutions.
The need to bolster routine immunization is being more widely recognized now.
Along with a focus on the operations front,i.e. ensuring supplies of vaccines and
syringes, maintenance of cold chain, deployment of health care providers etc, it
would also be crucial to focus on the social mobilization aspects of the
programme. Stakeholdersas well as beneficiaries would need to be informed and
mobilized to support as well as benefit from the programme. The immunization
figures which were at 11% have now increased to around 24% since the revival
of routine immunization in the state in August 2005. This would be further
stepped up to 80% by end 2007 through improved operations along with effective
as well as targeted social mobilization.
Social Mobilization has a very important role to play in bringing stakeholders
together, developing realistic and effective plans of action and helping
communities realize the benefits accruing from investing in immunization of
children keeping in mind the barriers and variables related to infrastructure and
socio-cultural traditionsand beliefs.The task becomes much more difficult if no
immediate tangible benefit is being offered or is visible to the communities and
the mobilization is expected to be effective enough to surpass all kind of barriers.

2. The social mobilization would need to be “Evidence Driven” i.e.there would need
to be sufficient body of evidence to be able to successfully link activities /
interventionsto outputs as well as outcomes and results.UNICEF experience in
the area of social mobilization for polio eradication has been able to demonstrate
just that. Through targeted interventions and activities, the UNICEF social
mobilization network has been able to effect positive changes in behaviors
through the polio eradication programme. Advocacy with media, celebrities as
well as policy makers has provided the enabling environment for the programme,
whereas mobilization through community level partners and influencers has
helped in reducing refusals, drop-outs and increasingoverall faithand conviction
about the programme in the minds of programme beneficiaries.
UNICEF is supporting the routine immunization programme in the state. A two
pronged strategy would be adopted. One the one hand, UNICEF would be
supporting strategic social mobilization interventionsat the state level that would
have a bearing on routine immunization throughout the state. This would be
mainly through the mass media and influencing policy. Further, UNICEF would
provide more focused and targeted social mobilization support in ten selected
districts. Nine districts would be chosen from each region and one would be the
convergent district of Vaishali. This paper attempts to provide a framework for a
social mobilization strategy related to the same.
Problem Analysis
Findings from the coverage evaluation survey and field visits provided valuable
insights into the issue at hand.
Coverage Levels were significantly higher for boys as compared to girls with
26.2% boys being fully immunized as compared to 24.5% girls. Also coverage
levelsshowed variationsby religion, with it being significantly lower for Muslims
as compared to Hindus with 27.2% Hindu children being immunized as
compared to 17.7% Muslims. Similarly, coverage levels were significantly lower
for SCs at 12.6% as compared to other caste groups at 30.1%. Importantly,
coverage levels showed significant improvements with socio-economic status of
the households and literacy of the mother.

3. Social exclusion issues were an area of concern. There was an acute ‘provider
bias’ in relation to people from socially excluded communities. Problems always
seemed to be identified by the providers among ‘Harijan tolas’. Providers were
found reluctant to do outreach in these areas. The behavior meted out by
providers to beneficiaries coming to the centre from these areas also deterred
them from doing so.
It had been observed that in about 37% of the cases in urban and 33% in rural
helpwas received from the husband in getting the infant immunized.Further, in
about one-third caseshelpwas also received from other family members, mainly
elderly women. The help received was generally accompanying the mother or
taking the child for immunization. Lack of support for mothers wanting to
immunize their children was reported. Often, husbands, mother –in-laws and
secondary audiences were found to be discouraging mothers from immunizing
their childrenas they felt it was unnecessary. The common explanation from in-
laws being “This was not required for our children, so why now?”. Thus reaching
out to the ‘gatekeepers’ i.e. people who have an influence on the way primary
audiencesfor communication behave would be of prime importance so that they
get an enabling environment to sustain the change in their behaviors.
The main reasons for non-immunization both in rural and urban areasreported
was lack of awareness (did not know about vaccination, did not understand
benefit of vaccination, immunization schedule), lack of motivation (aware of the
need and the facility but do not use services because of not getting time and
perception that child is too young and child was ill). In some cases non-
availability of vaccines was also a reason. Immunization wasquoted to be a low
priority among people with the perceived benefitsnot being clear. Lack of time to
take children to the health centre due to engagement with household chores as
well as livelihood was mentioned often. Some people could only say that “It is
good for our children’, but could not explain the exact benefits.

4. Only 23% mothers in urban and 13% in rural areas were aware of various
vaccines that an infant should get along with the age at which each is given.
However,those who were aware mentioned vaccination as very important, about
which they had known through discussion with health staff. Those who were
aware and answered mentioned that vaccination for children was very important.
Further, mothers who answered that they had discussion with health staff,
majority reported that health staff discussed with themabout the importance of
getting childrenimmunized. It was observed that the coverage levelswere higher
for those who were informed of the benefits by the health functionaries reinforcing
the need of orienting the health and other frontline functionaries on
communication and mobilization skills.
In many places, the caregivers were of the opinion that the child is ‘too young’ for
immunization, reinforcing the need to inform caregiversabout the correct age for
each vaccine.
The normal reactions following immunization and lack of counseling by the
providers related to the same was found to be another reason for drop-outs.
No major myths or misconceptions were found related to immunization. Deaths
following immunization due to other unrelated reasons however, were linked to
immunizationand had sometimessparked refusals and resistance insome areas.
However it was found that there is a wrong perception in the community that if
the child gets required pulse polio drops, he/she is fully immunized for all
diseases.
About 38% from rural areas were aware of the routine immunization sessions
held in their village; also 29% in urban areas reported that immunization
sessions were held in their place. About 40% from rural areas reported that
immunizationsessions were held in their village. Also,about 30% in urban areas
reported that immunization sessions were held at their place. It was reported
that these were held generally at the ICDS centre. Over 95% reported that the
sessions were held at the same place and reported that the place for

5. immunizationsessions was convenient. It was reported that these sessionswere
held monthly or weekly at the same place.
In relation to the general health seeking behaviors, both in rural and urban areas
majority reported as going to Private Doctors. Only about 9% in rural and 20%
in urban reported as going to Govt. Health facility. It was found that many people
belonging to higher castes go to private practitioners for immunizing their
children. People from lower castes often do not attend because of the treatment
meted out to them by the providers and people of higher castes at the centers.
Reasons for not immunizing children
Reasons* Rural Urban
Did not know about vaccination
Did not understand benefit of vaccination
Doctor/Health worker said it was not
necessary
Doctor/health worker advised against it
Did not know where to get immunization
Vaccine was not available
Child got sick after he/she got vaccination
Can not afford its cost
Fear of side effects
Fear of getting disease
Child was ill
Could not get time to go for vaccination
Was discouraged by family members
Against religion
Child was away
Child is too young
Others
24.3
17.0
1.5
1.5
8.5
8.3
2.1
8.3
3.7
1.0
1.1
6.5
12.9
7.2
0.3
0.9
25.1
3.2
20.9
13.7
2.6
0.9
2.0
3.7
2.9
6.3
4.6
4.3
6.6
15.1
4.0
2.6
0.6
9.7
12.0
2.6
N 1575 350

6. About 47% of households in rural areasand 54% in urban areas reported having
immunization cards. Communication would need to focus on the importance of
the same as it is an important tool for tracking service delivery as well as receipt.
The following table lists perceptionsof problems faced by communities related to
immunization.
Item Rural Urban
Facing problem
Yes
No
46.5
53.5
33.5
66.5
1996 647
Type of problems faced
Services not accessible when required
Fear of side effects
Quality of service is poor
Do not know vaccines, what vaccines are
needed and when
Do not know where to take child for
immunization
Vaccines are not available in the village
Vaccinesare not available at health centre
Too far to take the child
Do not have time to take child for
immunization
Cannot afford the cost
Behavior of health worker is not good
Others
8.3
8.9
15.4
14.4
16.9
22.0
12.6
19.5
7.6
11.5
3.4
9.8
7.8
24.5
12.0
14.2
6.1
10.7
10.6
5.0
10.6
17.4
1.3
11.9
928 217
Information had been collected from those who availed immunization services
about their opinion regarding non-utilizationof routine immunization servicesby
others. According to them not aware of the need and fear of side effects were the
main reasons for non-utilization of routine immunization services by others.

7. Opinion Rural Urban
Not aware of the need
Difficult to reach the place
Adverse rumors
Fear of side effects
Others/Don’t Know
35.4
5.1
3.6
22.5
33.4
34.8
3.2
4.7
25.7
31.6
954 342
The main source of information for routine immunization reported was Radio/TV,
Health worker (ANM/AWW/LHV), Husband, Family members as well as
neighbors and friends. In urban areas Private doctor was also reported as
important source. The most preferred source of information on immunization
reported was Radio/TV/Family members and health staff, which is in line with
the source currently providing the information.
Item
Rural Urban
Aware
Not Aware
12.9
87.1
23.3
76.7
1996 647

8. Source of Awareness
ANM/AWW/LHV
Govt. Doctor/Health Worker
Private Doctor
Social/NGO Worker
Radio/TV
Billboards, Posters at healthcentres,
booklets, news papers, etc
Husband/Family member
Traditional birth attendant
Pharmacist
Friends/Neighbours
Others
26.1
21.0
17.1
5.8
53.3
3.9
20.6
2.7
-
21.8
1.1
29.1
25.1
26.5
2.0
70.8
6.6
25.1
1.3
-
19.2
3.3
N 257 151
Preferred sources of information
ANM/AWW/LHV/Health Worker
Doctor
Social/NGO Worker
Radio/TV
Billboards, Posters at healthcentres,
booklets, news papers, etc
Husband/Family member
Traditional birth attendant
Pharmacist
Friends/Neighbors
34.2
33.5
5.4
98.4
2.3
35.0
-
-
26.8
27.8
42.4
8.6
98.7
11.9
33.1
-
-
19.9
257 151
Behavioral Analysis
The target audiences have been following certainpractices since ages, which have
become a way of life for them over the years. Thus changing them is a challenging

9. task. Constantly asking the target audiences to perform ‘clinically appropriate’
behaviors has often alienated target audiences from communication. Just asking
the audiences to accept a behaviour that is ‘appropriate’ according to prescribed
standards will not help as behaviors are closely linked to the environment that a
person lives in. Based on the barriers that exist, a ‘feasible’ or doable behaviour
has to be suggested. Along with the provision of messages to the target audience,
there is a need to also provide an enabling environment to help the audiences
sustain the change in behaviors. This is to be achieved by reaching out to the
secondary target audiences who influence the behaviour of target audiences.It is
important to remember that more often than not, people do things or behave in
ways that are acceptable or considered appropriate by people in their community.
Therefore reaching out to secondary audiences or ’gatekeepers’ assumes great
importance.
Health related behaviors are affected by multiple levels of influence. Individual
factors such as knowledge, attitudes and personal experiences; Interpersonal
factors such as family, peer group; Community factors such as social networks,
community norms and Institutional or Policy factors. Thus, taking account of
these levels of influence would be crucial.
It is extremely important to understand as to what is ‘of value’ to the target
audiences. What has maximum influence on their behaviour? Most importantly,
what is it that makes them do what they do? Most behaviors have a perceived
rationale or logic behind them. Unless social mobilization attempts to analyze
and address the same it would not be effective. There is often a perception that
most things happen, or are they way they are because they are destined so. The
connect between little things such as immunization that can be done at the
individual / household level and larger changesis absent. There is also a feeling
that all development is to be done by the government and the individual or
community has hardly any role / capacity related to the same.
There is lack of awareness about the importance as well as misconceptions
related to immunization. Low motivation to change behaviors arises from the lack

10. of knowledge regarding benefits related to practicing the same and social
conditioning. The community environment is also not supportive towards the
practice of immunization asperceived benefits are not clear.The service providers
lack the required communication and mobilization skills in order to convince
families, effectively address their curiosities, ally their fearsand put concernsat
rest. Inadequate counseling on side-effects of immunization also often leads to
cases of drop-outs. Sporadic service delivery, distance from delivery points and
non-addressal of community demands often also leads to alienation from health
services.
Participant Analysis
In order that social mobilization is effective, it should be relevant to the
participant groups. Therefore it is important to analyze the characteristicsof the
participant groups and find out how each group can maintain the practice of
desired behaviors. Different strategies, messages and channels will be needed to
address each group.
A. Primary Participants
Since the focus of mobilization is on increasing household awareness,
sensitization and motivation to ensure complete immunization, three primary
participants have been identified. They would be reached out to, using all
channels ranging from interpersonal to mass media.
1) Mothers (includingpregnant women) - The mother appears to be an important
participant going by the task at hand. The mother plays an important role in
looking after children and spends a major portion of her time doing the same.
Further, the issues related to looking after children is traditionally within the
domain of a woman’s responsibility. Hence, there will be a need to speak to the
woman in the household. While she may have limited decision making power but

11. can be a major influencer provided she understandsthe need of immunizing her
child.
2) Father / Head of the household – Traditionally, he maintainsa distance from
household and child rearing activities, but is an important participant as he is
the decision-maker in the household; almost all things are done post his
approval. Hence he needs to be sensitized towards the need for immunization.
3) Mother – in – law / Other caregivers – As a senior lady of the household, she
usually holds great influence over household and child rearing activities. She is
seen as someone who has great experience in the area and often takes important
decisionsrelated to the same. Thus reaching out to her and sensitizing her about
the need for immunization would greatly helpthe mother in practicing the same.
B. Secondary Participants
Although the primary participants and the focus will be the mother, husband
/head of the household and the mother-in-law, this strategy also has the
potential to generate awareness and change related to the issuesin the minds of
the following important secondary audiences:
1) AWWs /ANMs/ASHAs – These are frontline functionaries who come in direct
contact with mothers and families and thus need to be reached out to and
oriented on skills and issues for effectively engaging with families.
2) The community - including Village Level Communicators /Self-help groups,
PRI / Village health committee members, rural medical practitioners,
practitionersof alternative systemsof medicine, NGOs etc are the facilitators and
opinion makers, who are usually more informed and socially conscious. These
people can exert peer pressure as well as be role models for the unaware and
non- forth coming population. They would be systematically engaged with and
oriented so that they are better equipped to support primary participants.

12. 3) ‘Positive Deviants’ – Mothers and families which exhibit positive behavior in
relation to immunization, could be used as ‘role models’ in the community and
‘recruited’ to convince other families in their respective areas.
C. Tertiary Participants
1) Health and nutrition supervisors, managers and professional staff at sub-
centers, PHCs, district hospitals; members of local professional organizationsand
institutes - These participants are important as they are responsible for the
programme implementation at their levels and also help in creating a favorable
atmosphere for behavioral change to take place.
2) The Government including the various program administrators and policy
makers at state and district levels – Constant advocacy with this group would be
required in order to influence favorable policy for the programme.
3) Media and Celebrities – This segment has a tremendous impact in informing
and guiding decisions of programme beneficiaries as they are seen as reliable and
credible source of information.
Channel Analysis
The channels selected depend on both the target audiences that have to be
reached out to as well as the message content. Typically, an assortment of
channels are used in order to reach out to target participants for maximum
impact. Getting the correct ‘media mix’ is of crucial importance.
Mass Media
Audio Visual mass media is an effective way of reaching out to a large number of
people. It has great mass appeal as it is seenas a credible means of information
and entertainment by millions. It brings thoughts alive through pictures and
images and creates aspirational values in the minds of viewers. It has great power

13. in bringing about awareness on issues. However, weak programming can often
cause serious miscommunication.
The print media also has great reach, but is restricted to literate segmentsof the
target audiences. It is also seen as a credible source of information by millions.
In the context of Bihar where electrification is extremely low, TV might not be the
most appropriate medium. However, radio would definitely be a medium of
choice.
Folk Media
Folk media has great acceptance among target audiences and can be greatly
tailored to suit programme / audience needs. This is a medium which has great
potential in brining about behaviour change as the product of communication
through this form is as close to the audience as it can get. It isgreat for generating
discussions in the community. However, it is extremely challenging to implement
and monitor. Considering the acceptance and potential of folk media, it would be
use extensively.
Outdoor Media
Outdoor media in the form of hoardings, wall paintings etc. help in creating
visibility around the behaviour being promoted. It also acts as a constant
reminder to the target audiences. Monitoring the quality of implementation
however is often very difficult.
Interpersonal Communication
Interpersonal communication provides for two-way communication. The target
audience can get their queries and doubts addressed easily. Detailed information
can be provided which is difficult to provide through any other channel. Literacy
of the audiences is also not a bar. It has great potential in bringing about and
supporting sustained behaviour change.
The flip side is that the process is time consuming, and depends heavily on the
skills/ knowledge of the communicator. Its reach is also limited
Interpersonal communication by AWWs/ ANMs/ASHAs and other facilitators
would be key to the strategy. A great deal of interpersonal communication
activities are envisaged through them.

14. IEC materials
IEC materials are often not seen as a separate channel but greatly help in
communicating thoughtsand ideas. Posters,Banners, Leaflets, flipcharts, games
and activities, CDs all help in attracting target audiences and creating an
enabling atmosphere.
Objectives
The overall objective of the strategy along with the increase in immunization
services coverage from the current levelsof 24% to 80% by the end of 2007 would
be to influence positive behavior change among communities with respect to
immunizationresulting in sustained coverage and reduced drop-outs in the long
run. This would include enhancing knowledge regarding immunization and
encouraging conversion of the knowledge into practice and ensuring that
immunization is continued as per schedule. Strategic social mobilization for
immunization would meet the following broad objectives to help achieve the
programme goal of increasing immunization coverage and reducing drop-outs:
1. Identify behavioral issues and address them in order to increase
knowledge and awareness levels to make the communities more conscious
about the issuesrelated to immunization thus creatingan overall positive
environment to facilitate community mobilization and behavioral change.
2. Ensure that households are aware of the linkage between immunization
and child survival and development.

15. 3. Identify key actors at all levels ranging from the individual level to the
policy level and systematically engage them.
4. Maximize the impact of social mobilization efforts at the state,district and
block level by using a multi- sectoral approach, appropriate use of
technology, strengthening coordination amongst partners and effective
advocacy for supportive policy.
5. Increase coverage by establishing and informingdemand for immunization
Components of the Strategy
A two pronged strategy would be adopted. One the one hand, UNICEF would be
supporting strategic social mobilization interventionsat the state level that would
have a bearing on routine immunization throughout the state. This would be
mainly through the mass media as well as influencing policy. Further, UNICEF
would provide more focused and targeted social mobilization support in ten
selected districts.Nine districtswould be chosen from each region and one would
be the convergent district of Vaishali.
The communication and mobilization activities would endeavor to raise
awareness levels, influence attitudes and beliefs at the household and
community level in support of adoption of immunization and promote practice of
complete immunization .The strategy will build on a mix of social mobilization
activities, including advocacy, behavior change communication and community
mobilization.
State – Level Strategy
While the health department has undertaken many measures to improve
immunizationcoverage, it haslacked priority among people. Amongst the general
public as well as people’s representatives, other social and economic issueshave
taken precedence over child health. Therefore,the first stepshould be to highlight

16. immunization at various levels more prominently among communities,
implementers and the policy makers and relevant office bearers. Political support
is crucial to establish priority and commitment for the issue and ensure favorable
policy. The endorsement by the Government would also help relevant office
bearersto prioritize their plan of action. Advocacy will play a key role in ensuring
that there is a positive environment in which the immunization programme can
be implemented effectively. The primary area for advocacy focus would be on
working with partners (like elected representatives, media, celebrities etc) who
can increase visibility and credibility for the programme.
In order to extend the reachand impact of the strategy there should be a focused
effort to bring in new partners who can increase visibility and impact.
Partnerships can be initiated and be strengthened by making efforts to engage
the partners actively in communication for immunization. The strategy can also
seek to work closely with academic and professional groups to provide technical
inputs to the programme.
Advocacy
Advocacy at the state level will play a very crucial role. The thrust of Advocacy
will be to establish the context and relevance of the cause. An effective advocacy
campaign can also get support from media and can keep the issue alive for a
longer period of time in the public domain.
Advocacy through print media
Media is poised to play a significant role in improving the status of routine
immunizationin the state.The media's reachis vast, and the investmentsmade
for advocacy through media are cost-effective. Media enjoys a high degree of
credibility with the people and can be an effective partner for dissemination of
information. Working with the media is also important from the point of view of
averting possible negative coverage, which can be counter-productive. This is
especially true in the case of routine immunization (RI) programme which is
relatively new to Bihar, having been re-launched recently. Consequently, people
sometimes attribute infant and child deaths occurring due to various other

17. reasons to vaccine. Some of the possible activitiesfor print media partnershipon
Routine Immunization are:
1. Preparation of quality briefing package: The starting point for media
advocacy is often a good briefing note which presents the information
correctly and with lucidity. This will helpin keeping the media community
informed about Routine Immunization.
2. Workshops with District Public Relation Officers (DPROs): The Public
Relation Department has DPROs in all the districts. DPROs work closely
with the District Magistrates,Civil Surgeons and other district officialsand
working with the media is their mandate. UNICEF has a state level
partnershipwith the PRD and is in the process of orienting PROs to many
of the issues UNICEF works for. It is proposed that DPROs are supported
in holding two media workshops in each district between October 2006
and December 2007.
3. Media visits: In order to bridge the gap betweentheoretical knowledge and
ground reality, media exposure to the changing trends in routine
immunizationwill helpin keeping them interested in the programme.The
result will be regular media coverage and media monitoring of the
programme at the ground level. It is proposed that for each district,two to
three media visits are organised between now and December 2006. It is
proposed that capable NGOs are identified for organising field visits of
journalists.
4. Media Fellowships: There are many keen journalistswho are willingto take
some time off, travel with a purpose, and bring back a rich haul of stories
for their newspapers. This can be made possible through media
fellowships. Media fellowships for routine immunisation, for instance,with
The Hindustan Times will involve the signing of a Memorandum of
Understanding between UNICEF and Hindustan Times. The MoU will
specify the nature of grant, the conditions governing it such as how many
days the journalist will travel for, which subject or geographic areas
he/she will cover and how many stories he/she will come back with. The
paper will be committed to publishing at least a certainnumber of stories.

18. Media fellowships can be worked out with individual papers or in
partnership with, say, the State Health Society or the Public Relations
Department. UNICEF can do it alone as well. A panel comprising editors,
UNICEF and Government of Bihar will judge applications and award
fellowships.
5. Media Awards: A media award announced for a specific subject area leads
to a spurt in activity among all newspapers.A UNICEF award to journalists
for writing about Routine Immunisation islikely to lead to increased media
interest. The awards could be announced in partnership with the Public
relations Department or State Health Society. An award function at the
state level will ba an opportunity to discuss the importance of routine
immunisation and its connection withinfant and child survival as well as
recognise the work of journalists. A panel comprising UNICEF, State
Government and Editors will be constituted to judge the awardees, which
itselfwill strengthen the partnershipfor routine immunisation and renew
editors' commitment to the programme.
Advocacy through electronic media
Television penetration in Bihar is low. In reports about television penetration,
there is always a mention of Bihar since it occupies the lowest position in terms
of television penetration. A study by a marketing company in 2000 put the
television ownership figures at 3.7 per cent, while a 2004 study showed a
negligible increase. On the other hand Radio ownership figures in Bihar are
higher*. Radio remainsthe only source of information for families in many parts
of Bihar, particularly rural and hard to reach areas. The role of radio as channel
for information is therefore vital.
The following activities are proposed:
1. Radio spots on Routine Immunization especially during special
campaigns.
2. An entertainment based play covering both Routine Immunization and
Polio Eradication Programme
3. Programmes focusing on immunization could be supported on radio and
television. This will help in bringing the issue in the public domain,

19. generating the hype and possibly creating demand. This would also
motivate the political leadershipto take the issue upas a priority. Success
stories could also be broadcast in order to foster a positive image of health
care providers. News channels can be roped in to do dedicated
programming on immunization.
Advocacy through Celebrities
Celebrities add great credibility as well as visibility to any programme. Previous
experience of having used celebrities for promoting polio as well as routine
immunizationhave been positive. Celebrities would be particularly useful for the
launch of RI campaigns. They could also visit a few nearby sites to monitor the
activitiesand also give a media release to raise the profile as well as seriousness
of the programme.
Advocacy with policy makers
Mailers on the importance of immunization could be sent to the policy makers
and implementers. The mailer would reiterate the context and relevance of the
issue in the present scenario. It would also underline specific roles and
responsibilities vis-à-vis partners. Screen Savers on RI could also be developed
and installed on the computers of political leaders and decisionmakers in order
to buy ‘mindshare’ and assist the process of engaging them in the issue.
Advocacy with Partners for Coalition building
Partners from all quarters such as ICDS, NGOs, INGOs, SHG networks, PRI
representatives, Religious organizations, and occupational groups such as
COMPFED etc. would need to be brought into the fold in order to help in the
process of mobilization through their state-wide networks. They could also be
utilized to support district-specific social mobilization activities.
Strategy for 9 + 1 districts
District and Block Coordinators
A nodal person would be required at the district and block level, who would
coordinate activities at the same. The person would be involved in the

20. Identification and training of effective local partners/ volunteers and local
motivators who come in direct contact with families and communities on a
regular basis. These could be local SHGs, youth club members, PRIs, AWWs
/ANMs etc. They would also liaise with the concerned governmental authorities
in order to improve social mobilization and communication activities as well as
advocate for improving operations. UNICEF already has established a strong
social mobilization network for polio in 22 high-risk districts. The SMCs at the
district level and BMCs at the block level in these tendistricts would support the
programme. This would provide a great boost to RI as the target audiences for
both are the same and already established local partners and systems of polio
could be used for RI as well. This would also ensure that the newborns identified
during the round are give the immunization cards and brought into the fold of
RI.
Mass media campaign
The components of the state-level mass media campaign involving television,
radio and print media would also have a bearing on the selected districts. This
would be in the form of spots on radio as well as doordarshan placed before,
during and after programmes withhigh TRPs or listenership and advertisements
in national as well as local dailies. The same spots could also be played on local
cable TV networks.
Effective Interpersonal communication through ANMs and AWWs
The ANMs and AWWs are the cutting edge of any public healthprogramme as it
is through them that health and nutrition services are provided to the
community. They often lack effective social mobilization and interpersonal
communication skills, because of which they are often unable to effectively
counsel and motivate families. TOTs would be done with trainers from each
district,as well as trainers from AWTCs and ANMTCs on social mobilization and
communication skills. These trainers would in turn train AWWs and ANMs. Local
volunteers and mobilizers would also require a basic orientation. Thus the
workers would be better equipped while engaging withfamilies,communities and
local influencers alike.

21. Effective Interpersonal communication through Village Level
Communicators /Self-help groups, PRI / Village health committee
members, rural medical practitioners
Other channels for interpersonal communication would be explored for
promoting effective ‘parenting practices’ for child survival, with a focus on routine
immunization, so that primary audiences are exposed to the same messages by
people of their community creating an enabling environment for sustained
change in behavior.
Outdoor Media and IEC materials
The IEC materials/outdoor media will support interpersonal communication and
give credibility to the communicators.Outdoor media in the form of hoardings at
the district and state headquarters at strategic locations and wall paintings at
block / gram panchayat level would have to be put up in order to create visibility
as well as an enabling environment.
IEC Materials such as posters and banners would need to be developed and
supplied to the districts / blocks well in advance. The materials would need to be
put up according to a predetermined micro plan at strategic locations and not on
an ad hoc basis for ensuring maximum effectiveness. In the development of
outdoor media and the IEC materials, the following principles will be followed:
 Branding – All Outdoor media and IEC materials in support of the campaign
would need to follow a branding guideline i.e. all materials should have the
same ‘look and feel’. It should not seem that the materials are not connected
with each other. A brand ambassador would help in the branding process.
 Design - IEC materialsshould be taken as part of an entire package and not
seen on an individual stand –alone basis. The material would need to have
recall value, brand identity, and easy recognition and association with the
campaign. The materials would also need to be field tested before production
Cinema Slides / CD Shows
Cinema slides on immunization would be developed and distributed to local
movie halls for screening. Further an agreement could be entered into with DFP

22. for conducting CD shows followed by community discussions on immunization
in selected areas
Community Mobilization through local partners
Community mobilization is a critical element especially where a large number of
people are not concerned about the issue and do not understand its importance.
Community meetings,Block meetings, rallies etc. will need to be organized with
the help of local partners in order to mobilize the community in relation to the
issue.
Use of Folk Media
Folk media has great acceptance among target audiences and can be greatly
tailored to suit programme / audience needs. This is a medium which has great
potential in brining about behaviour change as the product of communication
through this form is as close to the audience as it can get. It isgreat for generating
discussions in the community. However, it is extremely challenging to implement
and monitor on a large scale. It could be used at select location as far as
practicable in collaboration with Song and Drama division
Promotion of RI by Village Volunteers in Vaishali
Youth volunteers in the convergent district of Vaishali are a huge force which
would be used to mobilize as well as motivate communities for routine
immunization. They would be provided a special input training on RI along with
their regular training. They would act as a link between the service providers and
the community and ensure that all children in their area comprising of 50
households are fully immunized.
Linking with LRGs in Dular districts
The dular districtshave a demonstrated, effective model for the promotion of child
health and nutrition through community volunteers called LRGs. These LRGs
would also be used in the common districts for the promotion of RI in their areas.
ASHAs

23. The ASHAs being recruited under the NRHM are a powerful source for social
mobilization. There would need to be a rational selection so that underserved
communities find representation in the same as otherwise mobilizing people from
the same would be a challenging task. They would need proper training on
communication and social mobilization, if they have to function efficiently. The
block as well as district management units would focus on the same as a priority.
‘Positive Deviance’
Mothers and familieswhichexhibit positive behavior in relation to immunization,
would be used as ‘role models’ in the community and ‘recruited’ to convince other
families in their respective areas.
Social Exclusion
Social exclusion is a phenomenon that is prevalent in the state. Unless there is
special attention given to the issue within the ambit of health programming,the
dream of immunizing all children will not turn into a reality. There are pockets
within many villages where either services do not reach due to bias on part of the
provider or community characteristics that are not conducive to immunization.
However, UNICEF experience in the area in the context of polio eradication
initiatives hastaught some valuable lessonsand the same canbe used for routine
immunization. An intensive mapping exercise has revealed certain pocketswhere
socially excluded or ‘underserved’ communities exist. Special strategies have
been designed to address issues in these communities.
Conscious effortswould be made to look at all activities through the lens of social
exclusion. The following initiatives would be incorporated in the programming:
1. Focus on immunization as a child right’s issue through the mass – media
component of the strategy
2. Forming strategic partnerships with religious, occupational and other
groups that elicit trust and credibility among socially excluded
communities and using them as advocates for the cause
3. Sensitization of frontline providers on the issue
4. Identifying social mobilizers/ partners from underserved communities for
underserved areas

24. 5. Increasing outreach in underserved areas
6. Development of need-based local communication material and local media
activities such as street plays, mosque announcements etc.
7. Through the work of the District management units, facilitating the
inclusion of underserved community institutions, in the planning,
implementation and monitoring of immunization activities at district and
block levels.
8. Using events, festivals, religious occasions of underserved for advocacy
and mobilization
Programme Management
A well established structure as well as systems would need to be in place in order
to implement as well as constantly monitor and assess effectiveness of
communication and mobilization activities.It would help measure outputs along
with identification of ‘best practices’ as well as areas for improvement.
Communication reach as well as effectiveness in promoting health-seeking
behavior would need to be assessed.
A. Coordination of Communication and Mobilization activities
 Coordination of communication activities for immunization as a part of child
health will be done by the state IEC bureau. A working group of partners
would need to be developed in order to conduct communication / mobilization
activities in a focused and concerted manner.
 Similar workinggroups in the form of District management units would need
to be developed at the district and block levels in order to create synergy and
facilitate communication efforts.
B. Sustained Capacity Building at District and Sub-district levels
It would crucial to ensure that the capacities of the functionaries in the above -
mentioned units at the district and sub-district levels are built as well as
constantly upgraded in order to effectively manage communication and social
mobilization initiatives. Quarterly or half –yearly, need-specific capacity building
sessionswould be organized at the district as well as the sub-regional levels.

25. C. Monitoring and Evaluation
Sharing Workshops
Half- yearly sharing workshops would be organized at district followed by state
level, to take stock of the progress made and lessons learnt. This will help in
modifying the strategy if necessary to achieve the desired results. Innovative
ideas, which have worked, can be shared at this forum and members can be
persuaded to adopt these ideas in order to achieve optimum results. The
achievement of implementers at various levels from district to village would be
highlighted to motivate them and to persuade the non-performers to learn from
them.
Ongoing monitoring
Ongoing monitoring of activitiesand reporting would be done by the district and
block coordinators supported by the district as well as sub-district management
units. This would helpensure quality of processes. Representativesfrom the state
management team would also conduct sample visits to programme areas.
Annual Assessments
Annual assessments would be done by external agencies in order to assess
effectiveness of activities and establish linkages with outcomes. Further, increase
in coverage, reduced drop-out’s etc. would be used as proxy indicators.
Treatment
The recommended strategy along with reaching out to the target audiences
directly will also facilitate behavioral change among the target audiences by
impacting at various levels in the external environment creating an enabling
environment for sustained behavioral change. The audiences will be empowered
with information at a micro level. The state level mass communication campaign
will be helpful in establishing the magnitude/ seriousness of issuesand thereby
creating a sense of urgency for the programme among the diverse set of
audiences. At the community level not only it will create awareness but it will
also help community influentials to persuade reluctant households. It will also
motivate support institutions like NGOs working in the areas, PRIs etc to gear up

26. for changing the situation and building upon the awareness created by the mass
communication campaign. At the administrative level, communication will help
in attracting the attention of relevant of office bearers associated with the project.
There would need to be some motivational triggers that will offset the desired
behavior change across the audiences and set a tone for the campaign.
Health is the trigger that is commonly used but it has not delivered the desired
result However, since health is the most common connect with immunization,
there is a strong need to establish the relationshipbetween the desired behaviors
and the expected health outcome/benefit.
Parents would have to be shown that immunization is a ‘worthwhile, low cost
investment’ for their children and urged to move out of their fatalistic approach
to life.
It would need to be demonstrated that a fruitful, productive life of their children
is actually in their hands and does not require much investment apart form a bit
of time at regular intervals for taking their children for immunization. There
might be many problems in their lives which do not have immediate solutions,
but then why not try and start with the small minor ones that are there in their
hands and could have a long lasting impact. It relatesto just looking at things in
a positive light and doing whatever is possible to better the quality of life within
the limited means.
Parents, caregivers and people in general have a strong emotional connect with
children and this very theme of emotional attachment could be used to
advantage. The trigger would focus on the lengths that parents go to for their
children. Immunization in that sense would be a small thing which parentscould
ensure for the happinessof their children.Would a parent like to have a disabled
child or be directly responsible for the death of his or her child?
The mass media, outdoor and IEC component of the strategy would have a child
making a direct emotional request to its parents asking them to ensure her survival
and healthy life by immunizing her. This would motivate parents emotionally as
parents often find it difficult to refuse an emotional request from their children. More
so, to do with their welfare.

27. ‘The child’ with a locally appropriate name and appearance would be the mascot
for the strategy, doing all the communication not just with the parents but with
diverse audiences ranging from elected representatives to policy makers to health
care providers and the like, with specific messages for each of the target audiences.
This so called ‘brand ambassador’ would help in people identifying with the
objective of the strategy well as give visibility and emotional appeal.
The creative focus would be to develop messages around this theme.

28. Messages, Target Audiences and Channels of Communication
Target Audience Messages (Basic themes. Require creative treatment) Channels of Communication
Primary Audience
Mothers, mothers-in-law,
caregivers, husbands
/head of the household
 Immunization helps in building the child’s
immunity and protects it from infections,
illnesses and even death- It is your child’s
birthright
 In order to get the benefit of immunization, all
does must be given to the child as per
schedule- The immunization card is crucial in
this regard.
 It is totally safe for your child and is available
free of cost
 More than one vaccine can be given in one day
without causing any harm
 There might be a few side-effects following
immunization- this is not a cause for worry,
but a sign that the vaccine is working. Find
out from the provider on how to deal with the
same.
 It is available at X location on Y date
IPC through AWW/ANM/Village
level communicators
Wall paintings, posters, hoardings
Radio, Theatre, CD shows, cinema
slides

29.  It is a small initiative that would go a long way
in ensuring that your children can lead a
healthy, long and productive life
Secondary Audience
AWWs, / ANMs /ASHAs
 Immunization helps in building the child’s
immunity and protects it from infections,
illnesses and even death- It is every child’s
birthright.
 Public health goals can never be achieved
unless all children are immunized- you have
the power to be a change agent for a healthy,
prosperous India.
Training on IPC Skills related to the
promotion of immunization social
exclusion, and visioning
Wall paintings, posters, hoardings
Radio, Theatre CD shows, cinema
slides
Secondary Audience
Village Level
Communicators /Self-
help groups, PRI /
Village health committee
members,
rural medical ractitioners
 Immunization is crucial for the survival,
growth and development of children in your
community. Help in promoting the same.
 Immunization helps in building the child’s
immunity and protects it from infections,
illnesses and even death- It is your child’s
birthright
 In order to get the benefit of immunization,all
does must be given to the child as per
Orientation for rural medical
practitioners, SHGs, Panchayats /
leaders who interact directly with
families
Wall paintings, poster, hoardings
Radio, theatre, CD shows, cinema
slides

30. schedule- The immunization card is crucial in
this regard.
 It is totally safe for your child and is available
free of cost
 More than one vaccine can be given in one day
without causing any harm
 There might be a few side-effects following
immunization- this is not a cause for worry,
but a sign that the vaccine is working. Find
out from the provider on how to deal with the
same.
 It is available at X location on Y date
 It is a small initiative that would go a long way
in ensuring that your children can lead a
healthy, long and productive life
Tertiary Audience
Health and nutrition
supervisors,
managers and
professional staff
at sub-centres, PHCs,
district hospitals;
 Continual and extensive promotion of
immunizationamong communitiesis required
to reinforce their behavior change
 Increase of visibility around immunization
Briefings, workshops and
orientations with health and
medical associations
Advocacy materials to senior
managers, administrators and
policy /decision makers

31. members of local
professional
organizations and
institutes, policy /
decision makers
 Promotion of immunization through public
engagements, visibility events and media
outreach
Sharing workshops
Joint field visits
Media articles / coverage
Activities Matrix
Audience Expected Results Activities Timeline
2006- 2007
Risks
Q4 Q1 Q2 Q3
(Family)
Mothers,
mothers-in-law,
caregivers
 Caregivers/mothers/mothers-
in-law can explain (knowledge)
why immunization is
important for the healthy
growth and survival of the
child
 Caregivers/mothers/mothers-
in-law believe (attitude) that
immunizationshould be given
to the child
Provision of
messages by front-
line workers through
direct home visits
Interpersonal
communication and
mobilization through
Village
communicators ,
X X
X
X
X
X
X
AWWs /ANMs not
available everywhere
Infrequent, unplanned
household visits by
front-line workers
Poorest households not
reached effectively due

32.  Mothers, mothers-in-law,
caregivers discuss (intention)
the importance of
immunization, and believe not
giving immunization can be
harmful (knowledge and
attitude)
 Mothers acquire skills to
initiate and maintain
immunization practice
(knowledge)
 Mothers practice
immunization with aided
support from AWW or other
community health workers
(practice)
self-help groups,
NGO workers and
PRI
Local and mass
media outreach
through radio, Song
and Drama, DFP,
cinema slides,
TV/cable and folk
artist groups
Development and
implementation of
outdoor media such
as hoardings and
wall paintings
X
X
X
X
X
X
to socio/economic
exclusion
Community networks
not available
everywhere,
Maintaining the
motivational levels of
volunteers. Proper
coordination of
volunteer activities
Lack of access to media
in the case of women
(Community)
AWWs, /
ANMs/ASHAs
 AWWs ,AMNs and ASHAs with
enhanced counseling and IPC
skills and sensitized on social
exclusion issues to
communicate effectively with
Development of
training module and
programme for
training of Master
trainers on
X Trickle-down training
insufficient to
strengthen counseling
and IPC skills; worker
motivational levels low

33. families to promote
immunization
 AWWs, ANMs and ASHAs
provide mothers with skills to
initiate immunization through
household level visits, prior to
and after the child’s birth
counseling and
interpersonal
communication skills
and social exclusion
Counseling skills and
interpersonal
communication
training for front-line
health and nutrition
workers
Development and
supply of IEC/IPC
materials
X
X
X
X
X
X
Inadequate/insufficient
HH contacts; social
exclusion
Inadequate
institutional reach to
urban poor families
(Community)
Village
communicators,
NGO workers,
self-help
 Village communicators
equipped with interpersonal
communication skills and
mobilized to promote
immunization – especially by
promoting family level support
IPC training for
village
communicators on
promoting
immunization
X X X Inactive or absence of
community groups,
networks and
volunteers

34. groups,
PRI/health
committee
members,
RMP’s
to the mother, and follow-up
at the 2-3 month period to
sustain the practice
 Self-helpgroups, Panchayats,
religious groups, effectively
mobilized to create a positive
village norm for
immunization, and also able
to ensure rural practitioners
promote accurate information
about immunization
 Communication material in
support of immunization used
by volunteers, rural medial
practitioners, SHGs & youth
groups when promoting
immunization
 Self-help groups, community
meetingsfacilitated to support
AWW in promoting
immunization in those homes
Orientation for rural
medical
practitioners, SHGs,
Panchayats/religious
networks who
interact directly with
families
Development and
supply of IEC/IPC
materials
Local and mass
media outreach
through radio, Song
and Drama, DFP,
cinema slides,
X
X
X
X
X
X
X
X
X
X
X
Inadequate skills and
knowledge to effectively
promote complete
immunization
Activity not monitored
and supervised
adequately
Media reach to rural
women typically poor
and inadequate

35. where immunization is not
practiced
TV/cable and folk
artist groups
Development and
implementation of
outdoor media such
as hoardings and
wall paintings
(Institutional)
Health and
nutrition
supervisors,
managers and
professional
staff at sub-
centres, PHCs,
district
hospitals;
members of
local
professional
 Supervisors, managers and
senior professional staff in
Family Welfare and WCD able
to advocate within their
departments and to district
and block administrators for
continual and intensive
support for efforts to promote
immunization
 Health centres (from sub-
centres to district hospitals)
and AWW centres increase
visibility around
Preparation and
dissemination of
advocacy materials
to senior managers
and administrators
Development and
implementation of
outdoor media such
as hoardings and
wall paintings
Regular briefings,
workshops and
X
X
X
X
X
X
X
X
X
X
Difficult to ensure
quality implementation
of outdoor media
Coordination with
professional bodies
often difficult.

36. organizations
and institutes
immunization through fixed-
site information posts
 Professional medical and
health associations in the
district effectively engaged to
promote immunization
through public engagements,
visibility events and media
outreach
orientations with
health and medical
associations
(Institutional)
Local and mass
media,
reporters,
producers,
station directors
 DD and AIR mobilized and
disseminating key messages
on immunization through
ongoing and special
programming, Public Service
Announcements and publicity
around immunization Week
 Song and Drama, Dept of Field
Publicity promoting
immunization at community
level through folk
MOU with DD and
AIR to support
increased
programming around
immunization
Content
development,
production support
for special and
ongoing
X
X X X
Insufficient
programming time
dedicated to
immunization
Outreach, quality of
implementation issues

37. performances, video and film
shows
 Print media providing
adequate and supportive
coverage
programming on DD
and AIR
MOU with S&D, FP
units and
implementation of
district level
communication
activities
Workshop with
DPROs
Development of
briefing package for
Media
Media visits/
Fellowships /
Awards
X
X
X
X
X
X
X
X