Final National RI Communication Strategy

Forewo
rd
At the end of 2018, the Government and people of Pakistan could be coming together in a
national celebration. Three achievable targets were set in 2013 for the country’s Expanded
Program on Immunization. One is the achievement of polio-free status for three years;
another is the elimination of neonatal tetanus and the third is a large reduction in childhood
morbidity and mortality due to measles.
Attaining these targets will result from a miraculous blend of hard work, political will, social
mobilization and good luck. Unfortunately, Pakistan is off track in achieving these and targets
and several Millennium Development Goals, including immunization goals. The number of
measles cases is thought to have eased off in 2014 from the 15,000 in 2012 and 25,000 in
2013, across all provinces (though with most in Punjab. In 2013, there were 898 tetanus, 183
diphtheria, 274 pertussis and 174 tuberculosis cases (the latter of which was restricted to
KPK). And, with respect to polio, the year 2014 was tough for Pakistan. The number of polio
cases reached 303, the highest in the world, prompting international calls for “surge support”
to Pakistan and Afghanistan.
While much of the success in reaching the 2018 targets depends on many factors, one tool
that may contribute to reducing Vaccine-Preventable Diseases morbidity and mortality is this
communication strategy. Creating demand for immunization and mobilizing communities to
advocate for improved basic health services and fully immunize their children is as important
as ensuring that the vaccines and competent healthcare providers are in place.
Having a communication strategy in place is therefore critical, and one of the most powerful
prerequisites for a sound communication strategy is evidence. This is recognized in the
Government’s Comprehensive Multi-Year Strategy on EPI 2014-2018, which calls for a
communication strategy underpinned by Knowledge, Attitudes and Practices studies. Now,
with the results of research in 2013 and 2014 recently available, we have the data to inform a
multi-year, implementable strategy.
The World Bank pointed out in its 2015 World Development Report: Mind, Society,
Behaviour, “Telling people that there is a way to improve their health is rarely sufficient to
change behaviour.” We know that knowledge and awareness are not enough to effect
behaviour and social change. This strategy is multi-pronged, suggesting a variety of
approaches that, combined, could move the country towards the immunization targets. Some
of the suggestions are for the federal Government to move forward; others are very much
meant for provincial and even UC and village levels.
One strategy for a country as large and diverse as Pakistan is difficult to apply in all places
and at all times. That is why this descriptive strategy will be accompanied by implementation
plans developed at the provincial level. This strategy should be seen as a guide for 2015
through 2018, adapted annually if changing circumstances require it.
3
Conten
ts
List of Tables, Boxes and
Figures
Acronyms
Messages
Executive Summary
Pakistan at a Glance and the 18th

Amendment
Background on the Expanded Program on Immunization (EPI) and t

Initiative (PEI)
The Expanded Program on Immunization

(EPI)
The Polio Eradication Initiative and Its Relationship

to EPI
Summary
The Evidence: Findings from 2014 Knowledge, Attitudes, Practices

Behaviours Studies
Polio Research
Routine Immunization
Research
Overall Conclusions
KAPB Findings by
Barrier
Discussion and
Recommendations
The Pakistan National Communication Strategy for Routine Immuni

2015-2018
Eight Core Elements of the

Strategy
Resource Requirements and

Funding
Discussion and
Recommendations
Bibliography
Annexes
Annex A. Theories of Change: Socio-Ecological Model and Health 14141
Belief Model
61718
Annex B. New Vaccine Introduction: Action Plan for
PCV-10 18191
Annex C. Key Characteristics of Communication Channels in 92131

Pakistan
31334
Annex D. cMYP Targets by
Province/Area 24345
Annex E. Matrices for Costed Implementation 47475

Plans
05255
05060
56
71213
List of Tables, Boxes

and Figures
Tables
Table 1. Childhood Vaccination Schedule in

Pakistan
Table 2. Attitude towards Immunization and (Self-reported) Practice of Immunization by Socio-Economic

Class
Table 3. Caregiver Awareness by (a) Disease and (b)

Vaccine
Table 4. LHW Awareness by (a) Disease and (b)

Vaccine
Table 5. Methods of Disease Prevention –

Knowledge
Table 6. LHW Beliefs about Peoples’ Use of Vaccination and of Alternative Methods of Disease Prevention and
Treatment
Table 7. Comparison of Immunization Status with Primary Communication

Source
Table 8. Time Spent on Commute and Wait and Money Spent on

Commute
Table 9. Lack of Vaccines (Reasons given by Caregivers to

LHWs)
Table 10. Reasons for skiping vaccines
Table 11. Milestones from 2015 through 2018 for increasing Routine
Immunization
Boxes
Box 1. Pakistan’s EPI Targets for End of 2018 and Outcome

Indicator
Box 2. Demand Generation, Communication and Advocacy in the Comprehensive Multi-Year Plan for EPI,
2014-2018
Box 3. Seven Barriers to Full Immunization of

Children
Box 4. Participant Analysis: Key to Successful

Communication
Box 5. Risk Communication Planning and

Implementation
Box 6. Barriers that can be Addressed through the

Advocacy
Figures
Figure 1. Province/Area Map of Islamic Republic of

Pakistan
Figure 2. Polio Cases in Pakistan, 2012-2014
Figure 3. Source of Awareness of Routine Immunization -

National
Figure 4. An Eight-pronged Communication Strategy

Flower
5
Acrony
ms
AEFI adverse events following immunization AJK Azad Kashmir Administrative
territory BAL Balochistan Province CDA Capital Development Authority
Administrative territory cMYP (Consolidated) Multi-Year Plan on EPI 2014-2018
C4D Communication for Development DC Deputy Commissioner DCO District
Coordination Officer DHCSO District Health Communication Support Officers DPEC
District Polio Eradication Committee EOC Emergency Operations Centre (for polio)
EPI Expanded Program on Immunization FATA Federally Administered Tribal
Areas Administrative territory FR Frontier Region GB Gilgit-Baltistan Administrative
territory ICT Islamabad Capital Territory Administrative territory IDPs Internally
Displaced Persons IEC Information, Education and Communication IPC
Interpersonal communication IPV Inactivated polio vaccine KP Khyber
Pakhtunkhwa Province LHV Lady Health Visitor LHS Lady Health Supervisor LHW
Lady Health Worker MoNHSRC Ministry of National Health Services, Regulations
and Coordination OPV Oral Polio Vaccine PDHS Pakistan Demographic and Health
Survey PUN Punjab Province RI Routine immunization SIN Sindh Province SM
Social Mobilizer UCMO Union Council Medical Officer UCO Union Council
Communication Officer UCPW Union Council Polio Worker UPEC Union Council
Polio Eradication Committee VPD Vaccine Preventable Disease WPV Wild
Poliovirus
Providing Immunization Services to every eligible child of Pakistan is a commitment of

the Government of Pakistan to the children of Pakistan – a commitment to save every
child from vaccine preventable diseases and to give a healthy future.
In the vision of the Prime Minister, Government of Pakistan, Muhammed Nawaz

Sharif is a country where no child ever will be afflicted by the disabling / crippling
vaccine- preventable diseases like Polio, Measles and Pneumonia. Improving
Immunization coverage is one of the main agenda of our Health manifesto and we are
working to fulfill that agenda. Our nation has proved that it has the resilience to
surmount any challenge and I am confident that under the leadership of our Prime
Minister and all Chief Ministers there is no reason why we should not achieve our
cherished goal of a Healthy Pakistan.
Immunization programme aims at protecting the children against vaccine-preventable

diseases. I believe that an effective communication is an important element in
achieving this objective. Communication can help to raise awareness, create and
sustain demand and encourage acceptance of vaccination services by the
communities.
In this regard, I really appreciate the initiative of the Federal EPI in designing and
developing a comprehensive document of the Communication Strategy for Routine
Immunization. I am sure this document will help in improving the quality of
communication interventions in the country to raise awareness about vaccination and
vaccine preventable diseases and contribute towards increasing coverage of Routine
Immunization in the country.
The technical assistance provided by the UNICEF in this regard is highly

appreciated.
Message by the
Minister of State
Ministry of National Health
Services, Regulations and
Coordination Saira Afzal
Tarar
7
The Federal Expanded Program on Immunization is the program of the Ministry of
National Health Services, Regulations and Coordination through which we provide
access to lifesaving vaccines and control and eradicate vaccine-preventable
diseases.
The Routine immunization communication strategy also creates opportunities to

educate parents about the benefits of vaccines and other health services.Educating
and mobilizing the public to support immunization and to use immunization services is
central to EPI. Commissioning of a Communication Strategy is a step to revitalize our
efforts in more coordinated and effective manner. The Federal EPI’s initiative of
developing a comprehensive guide to conduct evidence based, meaningful.
An effective Communication Strategy for Routine Immunization involves planned

actions and processes to reach, influence, and involve all relevant segments of
society from the National to the community level, in order to create an enabling
environment and effect positive behavior and social change for increasing trust,
acceptability of the immunization services.
I am sure, this strategy will prove its effectiveness with the course of time and we will
see improvement in future communication interventions to enhance promotion of RI
services. I also appreciate technical assistance extended by the UNICEF in
developing and printing of the Communication Strategy.
Message by
Secretary Ministry of
National Health
Services, Regulations
and Coordination Mr.
Muhammad Ayub
Sheikh
I am pleased to see this initiative of the Federal EPI. I believe that an effective
communication strategy can directly address problems in at least three ways: by
making more people aware of the benefits of immunization; by correcting false beliefs,
rumors, or concerns that prevent people from getting immunized; and by informing
people where and when to get immunized.
Recent studies have concluded that the lack of planned communication efforts has
had negative effects on immunization program performance and coverage in
developing countries because supply-sided actions alone cannot promote and sustain
a culture of immunization that affect demand for services. Effective communication by
health care providers has an important influence on people’s decisions about whether
or not to proceed with immunization.
The Communication strategy is a dynamic process that evolve and improve with the
passage of time and I am sure this document will serve as a guide through which the
Federal EPI and provincial EPI departments will get maximum benefit in designing the
communication activities.
I also appreciate technical assistance of the UNICEF in preparing of this

Communication Strategy document.
Message by the
Director General
Ministry of National Health
Services, Regulations and
Coordination Dr. Assad
Hafeez
9
The Expanded Program on Immunization (EPI) aims at assuring the provision of state
of the art equitable immunization services across the country that promote, protect
and preserve the health of the children of Pakistan. By doing so, the EPI has led to
improve the country’s health by creating a conducive place to live, work and play and
saving the children against the vaccine preventable diseases.
An important component of the Government of Pakistan’s Health Strategy is an

effective program of Immunization; by securing our children’s welfare, which gives
them the opportunity to live quality life, become productive future members of society
and to contribute to our collective task of nation-building. We require a focused
approach on four “Cs”: clarity of mission, communication, collaboration, and
coordination to ensure optimal performance of the program in Pakistan that will
ultimately contribute towards achievement and maintenance of all relevant
Sustainable Development Goals (SDG’s).
The effective flow of Information about the disease burden, cost-effectiveness of

vaccines, and demand creation is central to the program success in which
stakeholders make decisions to vaccinate their children against vaccine preventable
diseases. Therefore, we believe that no program can achieve desirable targets
without an effective Communication Strategy. Therefore realizing the significance of
the Communication for the program, Federal EPI has developed a comprehensive
document of the Communication Strategy for Routine Immunization 2015-2018. The
Communication Strategy for the Routine Immunization is a guiding document that will
help Federal EPI and provincial EPI departments in designing meaningful and result
oriented communication activities to promote Immunization program in the country.
The Federal EPI acknowledges the assistance and support extended by the UNICEF
in development and printing of the Communication Strategy for Routine Immunization.
Message by
National Program
Manager Expanded

Programme on Immunization
(EPI) Syed Saqlain
Ahmad Gilani
Thankfully we are living in an era where we have one of the most powerful and cost-
effective of all, health interventions, that is IMMUNIZATION. It prevents devastating
illness and disability, and saves millions of lives every year. Vaccines have the power,
not only to save, but also to transform lives – giving children a chance to grow up
healthy and improve their life prospects.
Increased demand for Routine Immunization (RI) is one of the key factors for
minimizing childhood mortality. Pakistan has a better chance of achieving the
health-related Millennium Development Goals by improving routine immunization
through intensified efforts. Sadly, routine immunization remains a major challenge in
Pakistan, despite the availability of effective and free of cost vaccines.
UNICEF in Pakistan works to provide safe, efficient and cost-effective vaccinations to

each and every child, even in remote and hard to access areas. We focus on
reducing inequities in immunization access and increasing vaccination coverage, and
increasing acceptance of, and demand for, immunization services. In addition to
vaccine procurement, UNICEF is supporting government of Pakistan in Advocacy,
Communication and Social Mobilization activities for RI. We are supporting the
Government to set up a communication system that allows involving and mobilizing
all the stakeholders including parliamentarians, community leaders, civil society,
parents and caretakers so that they can understand why it is important to immunize
their children and what results can they expect from these vaccines.
This Communication Strategy reveals the commitment of UNICEF and the national
Expanded Programme for Immunisation (EPI) for further strengthening RI in Pakistan.
We understand that the impact of information on immunization behavior is mediated
by socio-cultural and political influences, a situation that calls for locally appropriate
communication responses. Therefore, this document provides strategic
Communication for the Development framework, to improve and sustain health
practices and continuous engagement with communities.
UNICEF is committed to extend further support to the National EPI Program for
communication activities. This is just the first step towards success of an ambitious
global goal of a disease free world and will be taken as one of the most enduring
legacies for today’s children in Pakistan and the generations to follow.
Message by UNICEF
Representative in
Pakistan Ms.
Angela
Kearney
11
Executive
Summary 01
Three killer diseases. Measles, Tetanus and Polio
continue to sicken, disable and even kill Pakistani children
every year. Yet all can be eliminated as threats to
Pakistan’s diverse peoples through available, proven
solutions. The best solution is prevention, and effective
vaccines exist for all three diseases.
Pakistan’s Expanded Program on Immunization (EPI)

requires strengthening, and efforts are being made to
ensure that the country reaches targets established for
2018. While vaccines need to be available at all times and
health personnel need to be well trained and
compassionate, another important element is an
understanding by children’s caregivers of the importance
of immunization and their increased demand for
immunization services. One important strategy that can
contribute to a strengthened EPI system is
communication.
Many people believe that when someone knows about or

is aware of something that is good for his or her health,
she or he will automatically “adopt” a behaviour that is line
with the new knowledge or awareness. But though
knowledge and awareness are important, sometimes they
are not enough to overcome resistance to adopting a new
behaviour. In an effort to understand what caregivers
know and are aware of with respect to
vaccine-preventable diseases, vaccines and vaccination,
UNICEF supported several Knowledge, Attitudes and
Practices (KAP) studies or Rapid Assessment Surveys in
the 2013 and 2014. Three were province-specific around
polio issues, one was national in scope and focused on
routine immunization.
In the case of the national KAPB (including “Behaviours”)

study, the objectives were to provide an evidence base of
the knowledge, attitudes, practices and behaviours of
children’s caregivers, community members, health care
providers and programme managers regarding the
provision of health services and the main barriers to full
immunization of children. It also aimed to identify the most
frequent and credible information channels for
immunization knowledge and awareness. The resulting
reports are also important reference documents for policy
makers at federal, provincial/area and local levels as they
plan for strengthened primary health care services.
Coordination.
The evidence from the 2013-2014 studies provides solid
evidence that a few distinct barriers exist that preventThe strategy also proposes that an integrated and
caretakers from ensuring that their children are fullycomprehensive capacity development review and plan be
immunized, no matter what the effort that may be required.developed for health care providers and CSOs working on
The barriers include low awareness level amongstthe ground.
caregivers and healthcare providers regarding
A shift of resources from mass media (TV and radio) to
vaccine-preventable diseases and their risks; concerns of
community-level, dialogic communication is proposed,
caregivers about safety of Oral Polio Vaccine; belief in and
given clear evidence that caregivers rely on health care
use of local remedies for prevention and treatment; low
providers, family and friends for their information about
knowledge and awareness of health care workers
mmunization. Shifting the “communication machinery” will
regarding VPDs and their prevention; distance, time and
be challenging but the process must start.
cost of travel to health facility and long waiting time there;
unavailability of vaccines and vaccinators andAbove all, the strategy suggests that shifts in attitudes and
dissatisfaction with quality of service; and missingpractices within our own organizations are necessary.
vaccination card in the home. While overall percentages ofWith separate structures for polio and routine firmly in
caregivers who responded to questions aboutplace, it will take the support of top decision makers and
immunization may seem small, overcoming the barriers iseffort by everyone involved to conduct joint review and
absolutely vital to increasing childhood immunizationplanning meetings. They must begin in 2015.
levels in Pakistan.
This strategy should be seen as a menu of options from
Some of the barriers must be addressed through
which communication specialists at all levels, based on
strengthening of the overall health system. Others can be
their review of the KAPB studies, may select. They have
reduced through the effective use of communication.
other strategies and initiatives that have been successful
Based on the recent evidence, suggestions for the
n the past. They should all be considered, and, using the
effective and sustained use of communication approaches
solid evidence that is now available, selecting the right mix
– advocacy, individual and family empowerment,
of the right approaches and the most effective
community and group engagement and social mobilization
communication channels is possible. To reach the 2018
– are made in this strategy. Using the right mix of
targets, it is now necessary to move from talk of the
approaches and a variety of “channels”, Communication
“possible” to talk of “achieving the achievable.”
for Development, or C4D, can support shifts in attitudes
and practices at both the individual and group levels.
This strategy presents an overview of one small but

important aspect – childhood immunization – of the highly
complex environment in which Pakistani citizens find
themselves. A very brief summary of the 18th
Amendment, which devolved authority and responsibility in
many sectors, including health, from the federal
government to provincial governments, key results of the 02
KAP studies are provided. Differences amongst provinces
with respect to the barriers must be taken into the
consideration in the design of effective communication
strategies.
This document makes some overall suggestions for

consideration by the federal EPI Cell and the provincial With 188.5 million people, the Islamic Republic of Pakistan
authorities and communication specialists. For example, a (Jamhuryat Islami Pakistan) is the world’s sixth most
national campaign to revitalize Teeko or develop a new populous country. It is a federation of four provinces and
logo and slogan is suggested, as well as an updated five administrative territories, the latter of which are often
Meena series. Health modules being integrated into the referred to as “federal entities”:
school system at all grade levels is an existing proposal
from the Ministry of National Services, Regulations and • Balochistan (BAL) – Province
Republic. Amongst many other important provisions that
• Punjab (PUN) -- Province
decreased presidential powers by transferring them to the
• Sindh (SIN) – Province office of the Prime Minister and to Parliament, the 18th
Amendment transferred responsibility in the health sector
• Khyber Pakhtunkhwa (KP) -- Province
from the federal government to the provinces. This
• Azad Jammu Kashmir (AJK) -- Administrative territory process, widely called “devolution”, gave administrative
and financial autonomy to provincial governments.
• Federally Administered Tribal Areas (FATA) --
Administrative territory Hailed for the peaceful decentralization of power and the
recognition of provincial authority, the 18th Amendment
• Gilgit-Baltistan (GB) -- Administrative territory did not address details in carrying out its provisions.
• Islamabad Capital Territory (ICT) -- Administrative Though some kinks have been worked out over the past
territory four years, the devolution process continues to have
spinoff effects as politicians and other decision-makers
While AJK and GB, on the one hand, and KP and FATA,grapple with practical realities in implementation. The
on the other, are often paired together, significantMinistry of Health was abolished in 2011 and functions
differences in their living conditions, geography, economywere placed with at least six Ministries or Divisions.
and political conditions exist. These differences obligeInstitutional fragmentation followed, so in mid-2013, the
tailored approaches for communication as much theDivision of National and Health Services and Regulations
provinces require. was renamed as the Ministry of National Health Services,
A major change in Pakistan’s governance structures andRegulations and Coordination Division (MoNHSRC).
authorities occurred in 2010 with the passage by theLike other components of public health, the Expanded
National Assembly of Amendment XVIII to theProgram on Immunization (EPI) has not fared well in
Constitution. Referred to as the 18th Amendment, thisrecent years, compounded by side effects of the 18th
action shifted Amendment. One example of the weakened health system
s the 2012- 2013 measles epidemic, which saw more than
25,000 cases and more than 500 deaths. The EPI will be
explored further in the next chapter.
Khyber
Pakhtunkhwa
Federally Administered
Tribal Area
Jammu & Kashmir

Azad Kashmir
Pakistan from a semi-Presidential to a Parliamentary
Islamabad
Balochistan
Sindh
Figure 1 - Province/Area Map of Islamic Republic of
Pakistan
Punjab
Gilgit Bultistan
13
03
ded Program on
e Polio
Immunization is one of the most effective public health

interventions everywhere in the world. In Pakistan, the
Expanded Program on Immunization (EPI) was introduced in
1978 as a key element in the primary health care system. Its
basic aim is to reduce mortality and morbidity due to Vaccine
Preventable Diseases, specifically amongst children and
women. The Government estimates that if EPI were
discontinued, at least 1,000 Pakistani children under five years
of age would die every day , which amounts to a staggering
365,000 child deaths annually.
HS, Table 10.3.
Regulations and Coordination, Communications Comprehensive
THE EXPANDED PROGRAM ON

IMMUNIZATION (EPI)
The EPI encompasses nine childhood
diseases:
• Poliomyelitis
• Diphtheria
• Pertussis (whooping cough)
• Tuberculosis
• etanus
• Measles
• Hepatitis-B (introduced in 2003)
• Hib Meningitis (introduced in 2009)
• Pneumonia (introduced in 2012)
Despite almost 35 years of the EPI’s existence, in 2013, the

national average for a fully immunized child between 12 and 23
months was 54 per cent, with 66 per cent of children in urban
areas and 48 per cent in rural areas fully immunized . Coverage
varies by region, ranging from 16.4 per cent of children
considered fully immunized in Balochistan to 65.6 per cent in
Punjab.
Differences exist for girls and boys. While the national average
for the BCG vaccine, given at birth, is 86 per cent for boys and
84 per cent for girls, by a child’s twelfth month, girls have fallen
further behind, with 51.5 per cent fully immunized compared to
56 per cent of boys. Immunization of children with disability is
not tracked.
Table 1 shows the vaccination schedule as of January 2015.

The pneumococcal vaccine (called PCV) was introduced in
2010 and is being provided almost nationally; the inactivated
polio vaccine (IPV) has been introduced in some regions during
special campaigns and is projected for national introduction in
2015. Ways for communication to support introduction of new
vaccines nationally is discussed in the C4D Strategy, Chapter
5.
TABLE 1 - CHILDHOOD VACCINATION SCHEDULE IN PAKISTAN
Age Antigen Disease Prevented BCG Childhood Tuberculosis At Birth
OPV-0 Poliomyelitis Hepatitis-B Hepatitis-B
6 weeks
BOX 1 - PAKISTAN’S EPI TARGETS FOR END OF 2018 AND OUTCOME
INDICATOR
Measles: Reduction of measles morbidity and mortality by 50% compared to 2012 levels
Polio: Interruption of transmission of indigenous wild Poliovirus by end 2015 and certification of Polio-Free Pakistan
by end 2018
Tetanus: Elimination of Neonatal Tetanus by 2015 and maintain elimination status till 2018
The indicator in the cMYP that is suggested for communication is the percentage of children whose mothers intend to
vaccinate children.
The cMYPs also include projected resource requirements over the five-year period. “Demand side” or
communication- related activities are not detailed by line item or by year; a
Pentavalent–I Diphtheria, Tetanus, Pertussis, Haemophilus influenza B, & Hepatitis B Pneumococcal - I Hib
Pneumonia & Meningitis OPV-I Poliomyelitis
10 weeks
Pentavalent–II Diphtheria, Tetanus, Pertussis, Haemophilus influenza B, & Hepatitis B Pneumococcal - II Hib
Pneumonia & Meningitis OPV-II Poliomyelitis
14 weeks
Pentavalent–III Diphtheria, Tetanus, Pertussis, Haemophilus influenza B, & Hepatitis B Pneumococcal- III Hib
Pneumonia & Meningitis OPV-III Poliomyelitis IPV Poliomyelitis 9 months Measles-I Measles 15 months Measles-II
In 2013 and 2014, the Government of Pakistan, supported by the World Health Organization, The Vaccine Alliance
(also called GAVI), UNICEF and other partners undertook an extensive exercise to set targets for the EPI and to
define detailed Plans of Action for the five years between 2014 and 2018. The resulting Comprehensive Multi-Year
Plan 2014-2018 (cMYP) is a thorough examination and forward projections of routine immunization. It examined the
health
sector fully, from governance, workforce and financing the health system to service delivery, information management
and medical products and technology. The three targets set by the Government for EPI are in Box 1. Each province’s
Comprehensive Multi-Year Plan reflects “a vision of the sub- national authorities and partners of the developments of
immunization and strategic decisions necessary to achieve immunization outcomes.”
5. cMYP, page ? (Preface).
1 per cent allocation from the overall budget was foreseen. This communication strategy suggests a doubling of the
allocation to 2 per cent of overall EPI budget. Box 2 shows the strategies suggested for demand generation,
communication and advocacy in the cMYP; this strategy is in response to the call for an overall communication
strategy.
15
16
BOX 2 - DEMAND GENERATION, COMMUNICATION AND ADVOCACY IN THE
COMPREHENSIVE MULTI-YEAR PLAN FOR EPI, 2014-2018
The cMYP sets specific targets by province and area for measles, tetanus and polio and identified 13 indicators to
measure progress. The 13th indicator, to which communication can greatly contribute, is “Increased demand - % of
children whose mothers intend to vaccinate them”. No targets were set for this indicator.
Seven strategies were defined in the cMYP. The seventh strategy is Demand Generation, Communication and
Advocacy, the objective of which is “to improve knowledge and attitude toward immunization among target
population.” By 2018, it calls for
- X% of caregivers who understand benefits of immunization (or demonstrate proper knowledge of benefits)
increased from X to Y
- X% of caregivers will advise their friends/relatives/neighbors to vaccinate children regularly It was assumed that
baseline and target values would be defined based on the results of the UNICEF-supported national KAPB survey
that has now been completed (see Chapter 4). The cMYP went further by including strategies and activities. To
achieve “Immunization System Component (ISC) Objective 7, Knowledge and attitude toward immunization improved
among target population, the following four strategies were suggested:
• In short-run) Continue community mobilization and communication interventions that proved being effective (as
defined in provincial cMYPs)
• (In long-run) Develop and implement evidence-based communication strategies, and calling for Knowledge,
Attitudes and Practices studies to be undertaken and for the development and costing of a communication plan
• Integration of EPI and EPI communication (coordinated from the federal level and implemented at provincial and
sub-provincial levels), linked to Activity 1.5.1
• Inclusion of Routine Immunization in School curriculum (linked to NISP)
The cMYP strategies are further explored in Chapter 5, the Communication Strategy. THE
POLIO
ERADICATION INITIATIVE AND ITS RELATIONSHIP TO EPI
Over the years, Pakistan has always maintained polio
and Nigeria are the only other two polio-endemic countries, in the Expanded Programme on Immunization, with Oral
and Nigeria is headed towards eradication, perhaps in 2015. Polio Vaccine (OPV) provided at fixed health centres
and in
Afghanistan’s eradication efforts depend in large part on outreach activities. The OPV has also been used in repeated
Pakistan. campaigns to combat the wild poliovirus. As noted, the IPV, which is injectable, will be introduced to
Pakistan’s routine immunization schedule in 2015.
Figure 2 shows the increase of polio cases over the three-year period 2012 through 2014.
Unfortunately, in 2014, Pakistan and neighbouring Afghanistan were the only two countries where polio cases
increased. Two- 50year-old Shafi Muhammad’s name may soon be forgotten but 40the reality that this toddler from
Balochistan became the first child in 2015 to be confirmed as having polio will not. Little 30Shafi probably contracted
the wild poliovirus (WPV) in 2014, which saw 303 cases, more than 85 per cent of global cases. 20This is an
alarming figure for both Pakistan’s children and 10those in other countries in our inter-connected world. The “end
game” for polio globally is within tantalizing reach, but
0 challenges
remain before Pakistan can be declared polio-free.
The number of polio cases in Pakistan had been in decline
2014 since the 1990s, when the annual incidence of polio was
2013 more than 20,000 cases a year. By the late 1990s, cases had dropped greatly, from 1,100 in 1997 to 40 in 2006.
Cases
2012
began to climb again in 2007 , and the Government declared polio to be a national emergency in 2012. Today,
Afghanistan
Figure 2 - Pakistan Polio Case Counter
6. Chaghi district 7. Per Shelley Thakral, 10.01.15. Also: Mirza to confirm total 2014 cases on or around 15 February. 8. 2011 NEAP. 9. USAID, 2012.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2015 1
303 93
58
*Last updated on Jan 19th, 2015
In Under the first National Emergency Action Plan (NEAP) for Polio
response, polio technical and communication specialists Eradication in 2011, the government proposed the
establishment
conceived of “Health Camps”, an initiative that will bring together of a structure specifically to combat polio. These
included:
primary health care, nutrition, water and sanitation services in a. National Task Force b. Prime Minister’s Polio
Monitoring and Coordination Cell
some 2,500 under-served, “high-refusal” communities within known reservoirs of wild poliovirus in the country. The
Health Camp concept will enhance trust, gain access and promote c. National Steering Committee for PEI/EPI
caregivers’ demand for availability of health services to families d. National Vaccine Management Committee
who have refused the polio vaccine for their children. During the e. Provincial Task Force f. Inter-provincial
Committee on Polio (IPCP)
first phase in February 2015, the selected Union Councils will have the Health Camps implemented to families in
selected districts. The aim is to reduce the number of refusals for polio g. Provincial Steering Committee
vaccine and to improve access to other primary health care in the h. District Polio Eradication Committee (DPEC)
highest-risk districts, which are also amongst the most deprived
i. District Coordination Officer/ Deputy Commissioner
areas of basic services.
j. Tehsil Polio Eradication Committees (TPEC/Sub-division Polio Eradication Committee –SPEC)
k. Union Council Polio Eradication Committee
As discussions continue on the technical side of ensuring that all children receive the polio vaccine, on the
communication side, steps are being be taken to strengthen synergy between polio and routine immunization
advocacy and community mobilization. This structure has become semi-permanent and implements
For example, the COMNet, managed and financed for the polio multiple campaigns each year, taking the OPV
door-to-door in
eradication efforts, is a network of communication specialists high-risk districts. Well funded and operating as an
emergency
who are deployed in high-risk areas to deliver locally appropriate programme, the PEI, in the eyes of some, has been
at least partly
communication messages and initiate and promote appropriate responsible for a weakening of the Routine
Immunization system.
partnerships and other activities. More joint planning could be The 2014 NEAP established new entities: The Prime
Minister’s National Task Force, the prime Minister’s Polio Focus Group, the Prime Minister’s Polio Monitoring and
Coordination Cell and recently established Emergency Operations Centers (EOCs). Equivalent structures were put in
place in provinces, with the Chief Secretaries chairing the Provincial Task Forces. Recognizing that
done between PEI and EPI to share training resources (and training sessions) and materials and to undertake family
and community activities with the routine immunization networks. Understanding the existence of different cultures
and modus operandi that the emergency-oriented polio and the long-term routine programmes should not prevent
steps in 2015 to do joint planning. the routine immunization programme was sliding downhill, the 2014 NEAP also
stated, “Routine immunization continues to be
SUMMARY the backbone of polio eradication and is crucial for maintaining
Much of the responsibility for ensuring childhood immunization polio free status after the last polio case, and it will be
monitored
lies on the “supply side” of the EPI, that is, the availability of fully along with polio eradication activities12.”
functional health facilities with trained staff and availability of high-
There were 24 vaccine-derived poliovirus type 2 cases, mostly in North and South Waziristan. No WPV3 has been
recorded since April 2012. Some 93 per cent of WPV cases came from established polio reservoirs and
security-challenged areas of Peshawar, South KP, FATA, Karachi and Quetta13. Eighty-five per cent of cases in 2014
were from KP and FATA. Over 300,000 children in North Waziristan and South Waziristan, Khyber and FR
quality vaccines at all times. Some responsibility lies with the “demand side”, that is, with caretakers of children who
should ensure that their children are fully immunized, as well as other stakeholders who hold the national interest to
heart. To dialogue effectively with caretakers and healthcare providers about immunization and other aspects of
children’s overall wellbeing, communication theories and approaches come into play. Bannu had been unvaccinated
due to ongoing insecurity, though
Following the lengthy and rigorous cMYP process, a five-year eventually access was negotiated which allowed
vaccination at
communications strategy was developed by the EPI Cell of the basic health facilities and through door-to-door
campaigns in
MoNHSRC. It covers internal communications, to ensure adequate certain areas.
information sharing and to help increase knowledge amongst public
The growth in polio cases in Pakistan has generated much analysis and discussion at global and national levels. In
late 2014, recognizing the severity of the situation, an Emergency Operations Centre (EOC) was created in the
federal EPI building. While maintaining a focus on polio, the EOC was also tasked with ensuring synergy between the
PEI and the EPI and with other sectors, in an ongoing effort that has become known as “convergence.”
health professionals, and external communications, to “spread the word” about immunization amongst all
stakeholders. The external component covers Direct Communications mainly at national level, with stakeholders such
as media houses and academic institutions; Information, Education and Communication Materials for use at federal,
provincial and area levels; Event Management for observation of special days; Social Mobilization with a wide variety
of stakeholders; Lobbying and Outreach; Documentation; Knowledge Management; Media (Print, Electronic and
Social) and Website.
10. Polio Eradication & Endgame Strategic Plan 2013-2018, p.112 11. http://www.endpolio.com.pk/, downloaded 20.01.15 12. NEAP 2014, page 8. 13.
Note from UNICEF Polio Team, 19.01.2015.
17
18
To The underlying reason for this four-year communication strategy
move beyond materials-based one-time (or oft-repeated) is the focus it places on the application of Communication
for
campaigns towards long-term and holistic programming that Development (C4D) principles and approaches.
strengthens or introduces positive, healthy social norms, C4D C4D is also called development communication,
behaviour change communication and social change communication. It is a discipline that focuses on interactive
engagement amongst people and groups to achieve behaviour and social change. C4D promotes the creation of an
enabling environment that encourages and supports families and communities to act
principles and approaches should be applied. C4D ensures that the crosscutting principles of inclusion,
non-discrimination, participation and empowerment are addressed. Exclusion due to gender, ethnicity or caste,
disability and socio-economic status is addressed in meaningful ways. These principles, the SEM and other theories
of change are described in Annex A. positively for their wellbeing and to advocate for quality services
Finally, as noted in the Foreword, evidence-based data is the with decision makers at all levels.
starting point for a communication strategy. We now have results C4D as practiced by UNICEF uses a framework
called the
from research studies undertaken in 2013 and 2014. The next Socio-Ecological Model (SEM). The SEM addresses
the many
chapter summarizes the qualitative and quantitative data from layers of influence in a person’s life, including the
child’s home
research on routine immunization and the polio eradication environment, community and school settings, and the
national
initiative. and international social, economic and political landscapes.
04
The Evidence: Findings from 2014 Knowledge,
Attitudes, Practices and Behaviours Studies
Since the 18th Amendment went into effect, no extensive
of caregivers had heard their children should receive the Oral research had been undertaken to determine whether or
how there
Polio Vaccine (OPV) to be protected against polio. Ninety-nine may have been shifts in the knowledge, attitudes and
practices
per cent believed that message to be true. Most caregivers (KAP) of children’s caretakers and of healthcare providers
stated that they received information from their neighbours, across the country with respect to routine immunization
and
local doctors, religious and community leaders and most to the polio vaccine in particular. Provincial Plans of Action
trusted the neighbours and local doctors. While risk perception and the national cMYP uniformly called for qualitative
research
amongst caregivers for polio was a high 99 per cent, only 5 to be undertaken. Accordingly, UNICEF supported one in-
per cent said their children had received three doses of OPV. depth national study around routine immunization and
two rapid assessment polls around polio. The routine immunization KAP was undertaken in 2013/2014 by Oasis
Insights, LLC, a Pakistani consulting firm based in Karachi. For the polio sector, two KAP studies and one Rapid
Qualitative Assessment were conducted by the Harvard University School of Public Health in 2013 and 2014. These
research efforts have produced solid evidence for this communication strategy to make specific suggestions.
The Rapid Qualitative Assessment (RQA) on IDPs in KPK and FATA was conducted in October and November 2014
in communities that had been inaccessible to vaccinators since June 2012 due to a polio vaccination ban imposed by
militants. This study was conducted with the objective to understand the health & hygiene practices and its
maintenance, attitude of the community toward vaccines in general and polio vaccine in particular and the sources of
information about polio. Key findings from the RQA include: POLIO RESEARCH
The first polio study was conducted from November 2013 through January 2014 in 16 high risk areas in KP, FATA,
Balochistan and Sindh (Karachi). The overarching objective of the study was to understand the levels of knowledge,
trust and acceptance as well as existing practices and behaviours and sources of information in relation to polio
vaccination in Pakistan.
The second KAP research effort was a follow-up to the study described above and primarily focused on IDPs from
North Waziristan and South Waziristan. The objective of this survey was to assess caregiver awareness, knowledge
and perceptions of polio. Other objectives were to understand who influences decision making and the role of
community leaders in immunization decisions. The study shows that 99 per cent
• Males dominate access to knowledge, healthcare and healthcare solutions. Men are the chief decision makers and
wage earners and wield economic and moral influence within the household and family.
• According to community members, health and nutrition are a divine gift. These deeply held beliefs and fatalistic
attitudes were strengthened by the absence of qualified staff and equipped medical facilities. For any ailment among
children, home remedies get first preference. If they were ineffective, a maulvi14 or traditional healer was approached
for dam15 or taveez16 .
• Community leaders have an indirect influence over people since they are approached for solving domestic problems
pertaining to personal relationships and household matters. Jirgamaran and social workers act as a link
14. Maulvi or Mawlawi is an honorific religious title given to Muslim religious scholars preceding their names.
http://en.wikipedia.org/wiki/Mawlawi_(Islamic_title). 15. Dum darood is performed by maulvi or persons considered pious and religious. 16. Taveez is a
locket usually containing verses from the Quran or other Islamic prayers and symbols. The Taveez is worn with the belief that it will keep the wearer
safe
and bring good luck. Chishti, Hakim, The Book of Sufi Healing. New York: Inner Traditions International (1985).
other between the community and authorities for any of the
basic services, prevent complete compliance with the community’s problems. Local politicians also voice the
polio vaccination drives. They also highlight the challenges concerns of the community to the government.
of delivering vaccines in security-compromised areas. They
• Routine vaccination was widely accepted. However, the magnitude of the polio eradication drive and the frequency
of home visits for vaccination have escalated resistance among community members and also created indifference.
will be useful in reformulating strategies that demonstrate natural synergies between the Pakhtunwali values and
norms and between routine immunization and polio vaccination. The two polio-focused studies also complement the
findings in the comprehensive national KAP study undertaken in 2013-2014 on routine immunization.
• After seeing polio-infected individuals, many parents gave polio vaccines to their children. Some believed that only
vaccines that are expensive would be effective.
• IDP women had no previous knowledge about vaccination but were willing to vaccinate children if they received
permission from their husbands or religious leaders.
• Elderly women in the household possess some power in the decision-making process at family level. Some
grandmothers expressed the opinion that since they had led a comfortable life without being vaccinated for polio, that
was proof enough for them to resist giving the vaccine to their grandchildren.
ROUTINE IMMUNIZATION RESEARCH
The objectives of this UNICEF-supported KAPB study were to:
1. Provide an evidence base of knowledge, attitudes and practices of caregivers, community members, providers and
program managers, regarding health services provision and the main barriers for service utilization;
2. Identify credible information channels and networks for immunization knowledge, and to set the baseline for
progress in tracking the demand side of the national immunization programme; and
• Pro-vaccination individuals were willing to visit an EPI
3. Serve as a reference document for policy makers. centre, but worried about losing a day’s wage. They suggested
having temporary camps for IPV closer to settlements since EPI centres may prove expensive in terms of travel and
time.
With guidance from the MoNHSRC and others, the researchers organized focus group discussions and in-depth
interviews in seven regions and administered a survey in all four provinces. Forty-two focus group discussions and 80
in-depth interviews
• On the whole, vaccinator efforts were reluctantly appreciated. They were seen, however, as unqualified and without
knowledge of vaccination. Capability to
were conducted in 16 districts across the country to identify underlying reasons – often called “barriers” these days --
to full vaccination of all children. maintain the cold chain for polio vaccine was questioned, as vaccinators asked for
ice from residents. Community members were concerned about the security of staff after the incidents of kidnapping
and killing of people associated with polio vaccination.
A quantitative questionnaire was developed to explore the main themes emerging from analysis of the qualitative
results. The questionnaire was administered to 4,941 caregivers and 430 healthcare providers (Lady Health Workers)
across Pakistan. The qualitative element of the study included primary caregivers
• The Government’s focus on polio, with such huge funding, was consistently questioned. People were suspicious of
the government’s intentions for investing funds on polio vaccination without explaining the logic or
(mother, father, grandmother), Lady Health Workers (LHWs), Vaccinators, THOs (Tehsil Health Officers) and DHOs
(District Health Officers). The quantitative aspect was conducted with primary caregivers and Lady Health Workers.
addressing other basic needs. Village committees in FATA did not allow polio vaccination while they allowed other
OVERALL CONCLUSIONS routine vaccines.
The geographic features, population sizes, cultural and
• Radio appears to be the most reliable mode of mass
ethnic differences, political characteristics and availability of communication. Although television was present in
public services amongst Pakistan’s provinces and areas are some houses, shortage of electricity restricts viewing
and
thoroughly documented and analyzed in dozens of reports listening time. Most men had a mobile phone that was
and studies. They emerge, but are not explicitly described, used mostly for calling and not texting due to illiteracy.
in the study. The major categories used for the KAPB were Women could only operate ‘green’ and ‘red’ buttons
socio-economic class (SEC), education level and urban/rural. on mobiles. Hujras17 were a common meeting place
These three variables revealed interesting differences across for men, who act as a link between the women and the
provinces, indicating that changes in communication strategy outside world.
may be required to boost immunization levels everywhere.
These polio-specific studies indicate that misconceptions about the polio eradication effort, compounded by the lack
of
Table 2 presents an overview of attitudes towards immunization and actual practice, as reported by caregivers
themselves.
17. Hujra is a room where guests are entertained in many home in North India, Bangladesh and Pakistan. It is a place for men to relax and also for
community meetings.
19
20
TABLE 2 - ATTITUDE TOWARDS IMMUNIZATION AND (SELF-REPORTED)
PRACTICE OF IMMUNIZATION BY SOCIO-ECONOMIC CLASS
Attitude towards Immunization Practice of Immunization for Children* SEC Positive Neutral Negative
Fully
Immunized
Partially Immunized
Not immunized National average
A/B -- -- -- 86 12 3 C -- -- -- 80 14 6 D/E 38 52 61 71 19 10
KPK-FATA
A/B 86 12 3 97 2 1 C 81 12 8 93 4 3 D/E 89 8 3 89 8 3
AJK & GB
A/B 98 2 0 100 0 0 C 99 0 1 100 0 0 D/E 86 3 11 97 0 3
Balochistan
A/B 72 24 4 86 9 6 C 68 24 7 93 2 4 D/E 59 27 14 84 13 3
Sindh
A/B 78 15 7 95 3 2 C 66 22 12 90 8 2 D/E 57 28 16 93 7 1
Punjab
A/B 87 11 2 98 1 2 C 83 13 4 98 0 1 D/E 82 14 3 98 0 2
*Fully immunized - has received all vaccines due so far; Partially immunized – has received at least one vaccine due so far; Not
immunized – has received none of the vaccines due so far
The study also concludes that there is a perception among both caregivers and healthcare providers that the
immunization systems in Pakistan lack human resources, and that available staff are overloaded and unqualified.
Indeed, in the provinces, the EPI staff are tapped for polio campaigns, taking them away from the “fixed” health
facilities for as many as 120 days each year18. There is often not sufficient time for effective counselling and
information sharing. Perhaps partly for this reason, caregivers have certain doubts about the vaccines and about
immunization programmes. Some of these doubts relate to the efficacy, safety and quality of the vaccines. Other
doubts are about vaccine ingredients, particularly of the polio vaccine, and about the purpose of large-scale
vaccination campaigns.
Caregivers do not see vaccination as the only means of disease prevention. Many caregivers are likely to use home
remedies as an alternative. Home remedies are often easily
available and are supported by tradition, social customs and norms. Travel time and the financial cost of reaching a
healthcare facility were barriers in some provinces, though they were not seen as important barriers when averaged
at national level. Improving the ease of access to immunization facilities could be an important factor in raising
coverage in the future. The home-based vaccination record (vaccination card) is not currently optimally utilized as a
tool to improve routine coverage.
Taken together, the knowledge, attitudes and practices explored in this study were consolidated into seven barriers to
full immunization of all children. These barriers lie on both the supply and demand sides of the national EPI. All can
be addressed in some way by communication, though some lend themselves more readily to dialogic, participatory
and ongoing communication channels. The barriers are shown in Box 3.
18. Note from UNICEF Polio Team, 19.01.2015
BOX 3 - SEVEN BARRIERS TO FULL IMMUNIZATION OF CHILDREN

1. Low awareness level amongst caregivers and healthcare providers regarding vaccine-preventable diseases and
their risks
-- Demand
2. Concerns of caregivers about safety of Oral Polio Vaccine -- Demand
3. Belief in and use of local remedies for prevention and treatment – Demand and Supply
4. Low knowledge and awareness of health care workers regarding VPDs and their prevention -- Supply
5. Distance, time and cost of travel to health facility and long waiting time there – Demand and Supply
6. Unavailability of vaccines and vaccinators and dissatisfaction with quality of service – Supply and Demand
7. Missing vaccination card in the home -- Demand
Each barrier is explored briefly in the section below. Additional data in the national, province and area reports must
be studied
KAPB FINDINGS BY BARRIER [[

19. Spontaneous responses in AJK&GB; weighted response in Sindh.
and considered as each entity prepares its own implementation plan for the communication strategy.
Low awareness level amongst caregivers and healthcare providers regarding vaccine-preventable diseases and their
emand Side
risks D
Awareness about the vaccine-preventable diseases in the EPI amongst caregivers ranges from a low 1 per cent
about tetanus amongst caregivers in AJK and GB to a high 98 per cent about polio amongst caregivers in Sindh19 .
Mothers in all provinces/ areas described differences by disease. For example, one mother
in Sindh said, “During kalli khansi (pertussis), there is a lot of pain in the lungs, a lot of pain.” Regarding tetanus,
another mother said, “In this, the child gets convulsions and jerks, and the limbs stiffen and harden.” Table 3 shows
the levels of spontaneous and aided awareness by children’s caregivers of diseases and of vaccines.
TABLE 3 - CAREGIVER AWARENESS BY (A) DISEASE AND (B) VACCINE
(a) By Disease (b) By Vaccine Spontaneous Spontaneous
& Aided
Vaccine Spontaneous Spontaneous
& Aided KPK & FATA Polio 36 81 OPV 68 92 Measles 52 91 MMR 72 90 Pneumonia 36 72 PCV 36 56 Tuberculosis
22 61 BCG 29 56 Pertussis 23 47 Meningitis 4 18 36 56 Diphtheria 3 19 DPT 28 46 Tetanus 5 23 Pentavalent* 16 30
AJK & GB Polio 40 93 OPV 73 97 Measles 41 85 MMR 71 79
21
Pneumonia 43 98 (& Men.) 50 81 Tuberculosis 7 48 BCG 16 49 Pertussis 32 69 Meningitis 4 42 Diphtheria 2
25 DPT 14 55 Tetanus 1 33 Hepatitis B 8 56 HiB 9 47 Pentavalent* -- 58
Balochistan Polio 93 -- OPV 95 -- Measles 86 --
MR/MMR 72/74 -- Pneumonia 49 -- PCV -- -- Tuberculosis 65 -- BCG 71 -- Pertussis 79 -- Meningitis 34 --
Diphtheria 79 -- DPT 67 -- Tetanus 38 -- Hepatitis B 47 -- HiB 54 -- Pentavalent* 55 --
Sindh (Total Awareness, weighted) Polio 98
OPV 98 Measles 69 MMR 71 Pneumonia 73 PCV Tuberculosis 78 BCG 82 Pertussis 61
Hepatitis B 68 Meningitis 68 Diphtheria 33 DPT 58 Tetanus 42 Hepatitis B 68 HiB 68
Pentavalent* Rotavirus 0.5 / 99.5
Punjab
Urban Rural Polio 44 41
OPV 95 94 Measles 42 53 MR/MMR 74/62 78/58 Pneumonia 49 58 Tuberculosis 53 44 BCG 100 100
Pertussis 46 36 Meningitis 28 27 Diphtheria 40 23 DPT 92 91 Tetanus 32 27
Hepatitis B 37 26 94 92 Pentavalent* 85 88 Chicken Pox 56 56 Typhoid 50 51

*Pentavalent: Haemophilus Influenza type B, Diphtheria, Pertussis, Tetanus,
Hepatitis B
prompted, this increased to
Likewise, Lady Health Workers (LHWs) vary in their 100 per cent). In Punjab, LHWs seldom passed 50 per
familiarity with the major childhood diseases and the cent spontaneous VPD awareness. It seems clear that
vaccines that can prevent them. As shown in Table 4, as LHWs everywhere require more training, which should be
few as 15 per cent of LHWs in Balochistan hadprovided on a regularly scheduled, ongoing basis.
spontaneous awareness of tuberculosis (though when
TABLE 4 - LHW AWARENESS BY (A) DISEASE AND

(B) VACCINE
(a) By Disease (b) By Vaccine Urban Rural Vaccine Urban Rural

Spontaneous &
KPK & FATA Spontaneous Only;
Aided
Diseases in Your Areas
Polio 65 54 OPV 100 98 Measles 83 83 Measles/MMR 100/85 100/96 Pneumonia 70 72 PCV 100 100
Tuberculosis 83 86 BCG 100 100 Pertussis 76 65 Meningitis 48 41 Diphtheria 52 59 DPT 94 96 Tetanus 41 59
Hepatitis B 41 37 98 100 Pentavalent* 98 100
AJK & GB Spontaneous Urban Rural Polio 44 OPV 100 100 Measles 64 Measles/MMR
100/78 100/72 Pneumonia 81 PCV 89 89 Tuberculosis 58 BCG 100 100 Pertussis 61 Meningitis 33 Diphtheria
56 DPT 94 78 Tetanus 47 Hepatitis B 47 94 94 Pentavalent* 100 94
Balochistan Polio 29 96 OPV 100 100 Measles 25 100
Measles/MMR 100/12 100/12
23
Pneumonia 23 100 PCV 92/83 or 25/14? Tuberculosis 15 100 BCG 100 100 Pertussis 17 100 Meningitis 6
100 Diphtheria 15 100 DPT 100 100 Tetanus 15 100 Hepatitis B 10 100 100 100 Pentavalent* 100 100
Sindh (Total Awareness,
weighted)
Urban Rural
Polio 46 98 OPV 96 98 Measles 57 100 MMR 100/40 98/40 Pneumonia 67 99 PCV Tuberculosis 38 98 BCG
100 100 Pertussis 31 98 Meningitis 20 94 Diphtheria 23 91 DPT 92 90 Tetanus 30 90 Hepatitis B 21 95 96 92
PCV 95 96 92 Pentavalent* 86 77 90 85 Punjab Polio 44 41 OPV 95 94 Measles 42 53 Measles/MMR 94/62
96/58 Pneumonia 49 58 PCV 92 92 Tuberculosis 53 44 BCG 100 100 Pertussis 46 36 Meningitis 28 27
Diphtheria 40 23 DPT 92 91 Tetanus 32 27 Hepatitis B 37 26 94 92 Pentavalent* 85 88
*Pentavalent: Haemophilus Influenza type B, Diphtheria, Pertussis, Tetanus,

Hepatitis B
CONCERNS OF CAREGIVERS ABOUT SAFETY OF

ORAL POLIO VACCINE -- DEMAND SIDE
perspective, audience-specific messaging and a diversity
While most caregivers support vaccination, some
of channels should be used so that the doubts of these 24
expressed doubt about the safety of the Oral Polio
per cent are put to rest.
Vaccine. Of caregivers who had partially or unimmunized
children, 24 per cent nationally expressed doubt about Doubts about vaccine efficacy vary by province. In AJK, 99
quality of polio vaccines. An even smaller group carried per cent of caregivers are positive about the polio vaccine.
the misconception that polio vaccines might be “a The 1 per cent who expressed negativity either doubt the
machination against Muslims” or that they are a “Familyefficacy of the vaccine (children fall ill even after
planning injection”. From a rights vaccination) or have
a vague idea that this vaccine causes infertility in women. A notable number of caregivers in Sindh, Balochistan and
KPK/ FATA hold negative attitudes about immunization that this communication strategy should address.
For example, one District Superintendent for Vaccination, in Muzaffarabad, said, “It wasn’t like that from the
beginning
but now they don’t allow giving polio drops to their children. They said it is haram because they are from America.”
Another said, “We try to convince them that it’s not haram but they resist and say that it causes infertility. It’s a
conspiracy against Pakistan.”
BELIEF IN AND USE OF LOCAL REMEDIES FOR PREVENTION AND
TREATMENT -- DEMAND SIDE
Caregivers do not see immunization as the only means of
vaccination prevents disease, the highest knowledge of disease prevention and treatment. In the quantitative survey,
vaccine was for polio, at 70.9 per cent. most caregivers were aware that several diseases can be prevented through
vaccination, but large percentages of respondents also believe in other methods of prevention. Almost 19 per cent of
caregivers thought that measles could be prevented with home remedies and one in ten thought that pneumonia is
preventable in this way. Of the approximately
Healthcare providers confirmed these findings. Twenty-three per cent of LHWs responded that people in the area in
which they work are using home remedies to prevent measles; 11 per cent work in areas where pneumonia is
prevented using the same method.
48 per cent to 71 per cent of caregivers who believed that
TABLE 5 - METHODS OF DISEASE PREVENTION – KNOWLEDGE
Caregivers Tuberculosis Diphtheria Pertussis Tetanus Pneumonia Measles Polio
Method of prevention (Per cent of respondents) Allopathic Treatment 78.5 53.3 66.5 53.4 72.4 65.1 54.9
Homeopathic Treatment 4.2 4.2 3.7 3.0 3.4 3.7 1.9 Hakeemi Medicines 7.6 5.0 8.4 5.8 5.2 7.6 2.6 Vaccination
51.6 57.7 53.3 61.3 47.6 53.1 70.9 Desi Totkay** 3.4 3.8 10.4 5.2 10.4 18.7 2.8 Dam Darood** 3.0 2.0 3.1 3.4 3.1
6.6 2.4
LHWs
Tuberculosis Diphtheria Pertussis Tetanus Pneumonia Measles Polio
Method of prevention (Per cent of respondents) Allopathic Treatment 67 53 59 54 79 68 60 Homeopathic
Treatment 3 4 6 4 7 6 2 Hakeemi Medicines 5 7 9 4 7 7 4 Vaccination 60 59 58 60 57 61 65 Desi Totkay** 5 5 16
4 11 23 4 Dam Darood** 3 2 4 5 5 11 2
*Knowledge as used for the KAPB study: A set of understandings, awareness and knowledge. Knowledge of a health behaviour
considered to be beneficial, however, does not automatically mean that this behaviour will be followed. See full national KAPB report
for complete table.
**Desi totkay (home-based remedies); Dum durood (religious healers); Hakeemi (medicines prepared from herbs is hikmat and
hakeemi means use of herbs for the treatment of disease).
25
26
than Many caregivers use home remedies as a supplement or
immunization and are supported by traditions, social an alternative for illnesses, including the childhood Vaccine
customs and norms. Preventable Diseases. From Punjab, a mother said,
Another stated
They are “ “ “ “ often more easily available ” Table 6 compares by province what Lady
Health Workers have heard and observed with respect to caregivers’ use of
”
In Sindh, caregiver comments included
“““
We have syrups for cough and fever at home, first we use these.
I try home remedies first, like omum seeds but if the patient is serious, take him to the doctor.
From AJK, a father said
A mother offered
For For pertussis measles mostly we give mothers patient boil pigeon’s munakka soup.
in ”
”
milk, so measles can come out. traditional methods of disease treatment.
TABLE 6 - LHW BELIEFS ABOUT PEOPLES’ USE OF VACCINATION AND OF

ALTERNATIVE METHODS OF DISEASE PREVENTION AND TREATMENT
Reasons* KPK & FATA AJK & GB Balochistan Sindh Punjab Vaccinations 96 94 98 -- 68 Allopathic 93 64 40
90 -- Desi totkay 41 28 15 46 53 Dam darood 5 25 10 28 33 Hakeemi -- -- -- 28 --
Again, Lady Health Workers and other healthcare providers have a major role to play in convincing parents that
immunization is safe and effective. LHWs require information
The KAPB study showed that across Pakistan, healthcare providers are the primary and most trusted sources of
information about immunization. However, there is some perception among both caregivers and healthcare providers
that the immunization system lacks adequate human resources and that available staff are often overloaded and
unqualified. There is often not sufficient time for effective
They There are is no in a sympathy hurry and in are staff.
injecting as quickly as they can.
”
In GB, a mother observed
In AJK&GB, one mother said
They They don’t don’t talk talk and, possibly, increased opportunities for discussions with
doctors or nurses, on a regular, ongoing basis.
LOW KNOWLEDGE AND AWARENESS OF HEALTH CARE WORKERS
REGARDING VPDs AND THEIR PREVENTION - SUPPLY SIDE
counselling and information sharing.
In Balochistan, the largest and arguably the least developed province, 9 per cent of caregivers were not satisfied with
vaccination staff in fixed centres. This crept up to 15 per cent in Sindh. In Punjab, it was 9 percent, in KPK&FATA, 5
per cent, and in AJK-GB, 4 per cent.
much much; they they just just said said next next time time you you have have to to come come after after one one
month. month.
””
routine In AJK & GB, most healthcare providers are male, and
coverage. Some 90 per cent of caregivers rely on them because of cultural practices, mothers do not talk with them.
for information, followed by family members at 55 per cent As one mother confirmed, “Staff is male in these centres; I
and television at 40 per cent. Table 7 provides information can’t talk to them.”
about sources of information by province for caregivers with
The KAPB study provides conclusive evidence that healthcare
fully, partially or unimmunized children.
providers, including LHWs, play an essential role in extending
TABLE 7 - COMPARISON OF IMMUNIZATION STATUS WITH PRIMARY
COMMUNICATION SOURCE (UNWEIGHTED, PER CENT)
Primary Source of Information Fully
Immu- nized
Partially
Un-immu-
Fully Im-
Partially
Un-im- Immunized
nized
munized
Immunized
munized
KPK & FATA Sindh Healthcare Providers 93 94 81 95 94 85 Friend/Neighbour 31 26 20 44 35 43 Religious
Person 40 24 50 33 37 21 Family 60 64 57 32 26 18 Community Meetings 21 25 7 20 11 7 Rural Health Centres
19 13 8 -- -- -- Mobile Phones 10 19 4 6 9 12 School Teachers 3 6 4 5 7 6 Flyers 6 16 1 3 2 0 Mosque
Announcements 7 15 3 2 1 0
TV 4 2 0 1 1 1 Don’t Know 0 0 10 0 0 0
AJK & GB Punjab Healthcare Providers 97 100 100 87 93 86 Friend/Neighbour 33 40 38 49 53 43 Religious
Person 23 100 21 24 26 24 Family 39 100 93 41 38 46 Community Meetings 15 0 0 16 23 35 Rural Health
Centres 15 0 24 11 13 4 Mobile Phones 16 0 0 11 10 6 School Teachers 26 40 38 12 16 2 Flyers 9 0 0 12 6 5
Mosque Announcements 1 0 21 4 4 4
TV 4 0 21 4 2 1
Don’t Know 1 0 0 0 1 3
27
Balochistan Healthcare Providers 90 97 37
Friend/Neighbour 8 5 0 Religious Person 58 38 91 Family 58 39 80
Community Meetings 3 2 0 Rural Health Centres 4 8 0 Mobile Phones
22 14 29 School Teachers 3 1 0 Flyers 0 1 2 Mosque Announcements
300
TV 0 4 0
Don’t Know 1 2 0
national, mass media based messaging and towards
With healthcare providers as source of awareness about district- and community-level dialogue and social
VPDs and vaccines at the top of the list in every province, mobilization efforts.
their knowledge of and attitudes about VPDs and DISTANCE, TIME AND COST OF
immunization and their ability to convey effectively the
importance of immunization will be key to overcoming this
TRAVEL TO HEALTH FACILITY AND
barrier. It is critical that communication contribute to LONG WAITING THEM THERE - SUPPLY
overcoming the barrier of risk perception towards SIDE AND DEMAND SIDE
healthcare providers. Healthcare providers of all titles and
functions should possess the three qualities of credibility: Travel time, travel cost and waiting time seem to be mid-
competence, trustworthiness, and dynamism (charisma) in level barriers when averaged at national level. Important
service provision. This strategy includes actions that will differences emerge at the province/area levels. Caregivers
help strengthen these characteristics. of unimmunized children in AJK and GB are spending up
to Rs447 and 153 minutes waiting, compared to their
Television does not exceed 40 per cent of caregivers Sources of Awareness - RI
nationally who are fully or partially aware of routine (National)
immunization. In AJK & GB, TV is a source of information
for 4 per cent of caregivers of fully immunized children and 90%
for 21 per cent of caregivers of unimmunized children.
55%
40%
13%
25% 9% 7%
ealthcare...
H
ds...
ds...
utdoor...
O
utdoor...
O
utdoor...
O
AD / NP /
R
MAG...
AD / NP /
R
MAG...
The most trusted sources of information should be
AD / NP /
examined carefully in each province and at federal level to R
determine where to focus communication efforts and MAG...
allocate resources. The research indicates that healthcare AD / NP /
R
providers – perhaps of all types – are the most frequent
MAG...
source of information about immunization. Thus, additional
resources should be funneled away from high-level,
thers... thers...
O O
thers... thers...
O O
thers...
O
Figure 3 - Source of Awareness of Routine Immunization -

National
counterparts in Punjab, who spend Rs79 on transport to health facilities and 35 minutes of waiting.
The commuting times also vary greatly by province and by caretakers with fully, partially and not immunized children.
Distance to the facility and availability of public transportation were also factors.
In AJK & GB, 11 per cent of rural caregivers said they do not have enough money for the commute. They also noted
that
access to reliable transport is limited. One mother said, “We have to take lift and cross the river to reach CMH.” A
father said, “We have to spend 100 rupees to reach health centre.”
Table 8 indicates that time and money are factors that should be considered when discussing the importance of
immunization with caregivers. While these are also supply side issues, strong advocacy and dialogue with caregivers
may help convince them to invest the time and money into ensuring full immunization of their children.
TABLE 8 - TIME SPENT ON COMMUTE AND WAIT AND MONEY SPENT ON
COMMUTE
Commuting Time, Commuting Cost and Waiting Time
Fully Immunized Partially Immunized Not immunized
KPK-FATA
Commuting time (Avg in minutes) 46 47 57 Amount spent on commute (Avg in Rs.) 49 45 173 Waiting time at facility
(Avg. in minutes) 42 46 39
AJK & GB
Commuting time (Avg in minutes) 39 57 118 Amount spent on commute (Avg in Rs.) 61 150 447 Waiting time at
facility (Avg. in minutes) 41 57 153
Balochistan
Sindh (No table)
Commuting time (Avg in minutes) Amount spent on commute (Avg in Rs.) 49 86 Waiting time at facility (Avg. in
minutes) 43 43
Punjab
Improving the ease of access to immunization facilities could
approaches can be used to motivate parents to devote the be an important factor in raising coverage in the future.
time and money to have their children vaccinated. Cash or While this is mainly a supple side issue, communication
food incentives could also be considered.
UNAVAILABILITY OF VACCINES AND VACCINATORS AND
DISSATISFACTION WITH QUALITY OF SERVICE -- SUPPLY SIDE
Concerns were expressed in the KAPB research about the
factor in staff shortages at vaccination centres. regular absence of vaccinators and the lack of vaccines. One father in
Shikarpur, Sindh, said, “It has happened to me twice that I took my child to the centre and they said go back and
come tomorrow, we don’t have the dose today.” Another in AJK said, “When we reach hospital, sometimes doctors
are not available and sometimes ask to come next week because they don’t have vaccine.
Staff explained that one consequence of staff and vaccine shortage is keeping caregivers waiting or asking them to
return on a different day. Likewise, to reduce wastage, multi- dose vials will sometimes not be opened before it is
evident that enough eligible children will attend the session20. A District Superintendent for Vaccination (DSV) in
Punjab said, “We don’t have cold room; we are using refrigerator instead Healthcare providers themselves
highlighted the shortage of
of cold room.” There are also issues with weak cold chain staff and insufficient facilities across the country as a
barrier
capacity in many places. Some fixed centres dedicate a to an effective immunization system. One District Health
single weekday to a particular vaccine, and caregivers are Officer in Chakwal, Punjab, said, “We have limited budget
for
turned away and told to return later. The qualitative study travel and conveyance; we can’t visit far areas because of
also suggested that with so many children to vaccinate in that.” Failure of provincial governments to provide transport
each session, vaccinators do not feel they have enough time for staff for outreach may be one reason for
unimmunized
to provide adequate counselling to caregivers. children. Late payment of salaries was also named as a main
20. Frequency of absent staff and unavailable vaccines was not explored in the KAPB study nor has the consultant identified an alternate source of
information.
29
30
province The quantitative survey confirmed many of these concerns,
and area for this barrier is seen in Table 9. AJK&GB although nationally, 60 per cent of respondents were
shows the least absence of vaccines for both urban and completely satisfied with government vaccination staff.
rural parents, while Sindh has the poorest record. In Sindh, Of respondents with fully immunized children, 63 per cent
a staggering 30 per cent of urban and 33 per cent of rural were completely satisfied with the government vaccination
parents arrive at the health center only to discover that one staff. Satisfaction dropped to 12 per cent for those who
or more vaccine is not available. with partially or unimmunized children. Great variance by
TABLE 9 - LACK OF VACCINES (REASONS GIVEN BY CAREGIVERS TO LHWS)
Reasons KPK & FATA AJK & GB Balochistan Sindh Punjab Parents visit the vaccination centres but the
vaccines are not available Urban - % 15 0 8 30 12 Rural - % 17 6 29 33 8
Communication can be used to advocate at federal and
vaccination, 22 per cent of caregivers with partially or not province levels for systems strengthening to ensure a
steady
immunized children said nobody had reminded. When LHWs supply of vaccines.
were asked what the main reasons are for caregivers missing vaccination sessions, about 14 per cent said that it was
due MISSING VACCINATION CARD IN THE HOME - DEMAND SIDE
The home-based vaccination card is not optimally utilized as a tool to improve routine coverage. Several questions
about the availability of a vaccination card (in the home) and its accuracy were asked. It seems to serve a dual
purpose: reminding caregivers when the next vaccination is due and providing the vaccinator information about the
vaccines already given.
The qualitative research showed that “caregivers were generally familiar with the vaccination card but struggled to
explain the reason for retaining the card other than as a reminder of the time of the next visit.” Also, participants who
had misplaced the card typically expected that it could be easily replaced.
In the quantitative survey, when asked why they missed a
to the caregiver forgetting because the vaccination card was misplaced or lost.
Having the vaccination card was to some extent a predictor of immunization. Among children who were not
immunized, 82 per cent of caregivers had not retained the card. Of fully immunized children, 58 per cent of caregivers
had the card and 42 per cent had not. Among caregivers who did not have the card, 49 per cent said the card had
been lost, damaged or thrown away, and 14 per cent claimed never to have received it. Again, differences by
Province exist. Table 10 shows that close

to 40 per cent of urban caregivers in Balochistan forget to have their
children vaccinated because the card with the routine schedule is misplaced or lost, whereas this dips to 6 per cent in
AJK and GB.
TABLE 10 - REASONS FOR SKIPING VACCINES
Reasons for skipping vaccines Urban Rural KPK-FATA We forget to get vaccinated/Card is misplaced 26 17 AJK
& GB We forget to get vaccinated/Card is misplaced 6 6 Balochistan We forget to get vaccinated/Card is misplaced
38 29 Sindh We forget to get vaccinated/Card is misplaced 20 15 Punjab We forget to get vaccinated/Card is
misplaced 13 4 National We forget to get vaccinated/Card is misplaced 26 17
In addition, when the card is retained, it is sometimes incorrectly filled out. Inaccurate or incomplete information thus
complicates the record-keeping process.
The research indicates that the absence of vaccination cards, compounded by cards that are incorrectly filled out,
may affect immunization coverage. One option for improving retention is to better explain the card’s purpose and
benefits to caregivers, for example through IEC materials and public service announcements in the media. Better
information to, and engagement with, caregivers will be required if Pakistan
approaches retains a home-based immunization record system. Another
to tailored provincial approaches that include option is to move away from the home-based model in which
more interpersonal communication offered through a greater the caregiver is responsible for the cards and to keep
the
diversity of communication channels and approaches. vaccination record at the health facility.
Vaccine reluctance seems restricted to the polio vaccine. Since most caregivers receive and trust information about
DISCUSSION AND RECOMMENDATIONS
The 2014 research study and polls provide solid qualitative and quantitative data about caregiver knowledge of,
attitudes towards and practices around routine immunization and polio immunization. While polls, surveys and other
research globally are open to interpretation, when well conceived, scientifically recognized methodologies are used,
the results provide a foundation for action.
The KAPB research and the polio polls offer enough data from which three overarching conclusions be drawn. These
are as relevant for decision makers and EPI specialists as for communication specialists.
polio from neighbours, health care providers, religious leaders and traditional healers, empowering those groups of
people to “carry the immunization torch” is key. In the non- FATA areas included in the polio polls, it should be noted
that 22 per cent of caregivers receive but not trust religious leaders with respect to polio drops.
Third, a communication strategy developed for use nationally can provide overall guidance, but the evidence needs to
be studied carefully to tailor the approach for specific groups and for geographic area. At federal level, actions should
be guided by functions that have been defined in the wake of devolution, which include (amongst others) policy and
regulation, financing, service delivery and human resources, First, the barriers must be addressed by the technical,
“systems” side of institutional strengthening and the communication, “demand side” of immunization. While
communication can reduce doubts and contribute to strengthened knowledge and awareness, it cannot ensure
vaccine supply or reduced transportation time and cost
and information. For this communication strategy, federal EPI might lend its weight to ensuring adequate resources to
communication, initiating national communication activities as suggested in the next chapter and on supporting
provinces with celebrity involvement, materials development as requested and other areas as may arise. to health
centres. It can attempt to convince caregivers to spend the time and money to have their children immunized, but in
the end, even motivated parents will refrain making the effort if they have even a second negative experience.
Other more province/area specific conclusions can be drawn from the new bodies of evidence. They are explored
further in the next chapter, which is the Pakistan Communication for Development Strategy for Routine Immunization,
2015-2018. Second, the evidence now at hand signals the need for a change in emphasis from nationally driven,
mass media
05
The Pakistan National Communication Strategy for
Routine Immunization, 2015-2018
This chapter may be extracted from the rest of the document and used as a stand-alone document. Mindful of the
timing of this strategy, which comes after work plans or action plans for 2015 have been developed, it nonetheless
offers ideas that can be integrated into existing plans or initiated during this first year of the remaining four years of
the cMYP. Likewise, the approaches and suggestions remain applicable throughout the lifetime of the strategy. A
Consultation Meeting held on 6-7 January 2015 provided invaluable inputs to the strategy.
This strategy is intended to recharge the EPI communication efforts by proposing suggestions to reduce caregiver
reluctance or resistance and increase uptake and demand for immunization services. Some of the suggestions are
easier to implement than others, which require political commitment and adequate resource. Some are offered to
promote communication convergence between RI and polio.
The strategy dreams of galvanizing broad political and social commitment throughout the country to attain the 2018
targets for measles, tetanus and polio.
Highlights of this strategy include:
• Using a greater mix of communication channels at all
levels (national, provincial / area, district and UC)
• Shifting resources to provinces and areas from mass media and events-based approaches, which are expensive, to
learning and dialogue opportunities at district and village level and for production and dissemination of age-relevant
and audience-specific materials
• Developing a progressive and ongoing capacity development strategy for healthcare providers and others
• Encouraging an adapted approach for each province, area and federal entity based on the evidence
31
32
• • Inspiring, involving and strengthening civil society
Low awareness level amongst caregivers and healthcare
• Building partnerships with the media for positive coverage on public health issues
providers regarding vaccine-preventable diseases and their risks -- Demand
• Building partnerships with the private sector
• Concerns of caregivers about safety of Oral Polio Vaccine -- Demand
• Planning for introduction of new vaccines, specifically IPV in 2015
• Belief in and use of local remedies for prevention and treatment – Demand and Supply
• Providing for risk communication
• Low knowledge and awareness of health care workers In Pakistan, the application of strategic behavioural and
social
regarding VPDs and their prevention -- Supply change communication as a holistic and interactive process with
individuals and communities is beginning to take root. A wave of volunteerism in the 1980s and early 1990s to bring
• Distance, time and cost of travel to health facility and long waiting time there – Demand and Supply
immunization levels to almost 80 per cent nationally could
• Unavailability of vaccines and vaccinators and be revived. Indeed, thousands of civil society organizations
dissatisfaction with quality of service – Supply and operate in ways small and large throughout the country.
Demand Though the situation may have changed, in 2002, almost half of the non-profit organizations were involved
in education,
• Missing vaccination card in the home -- Demand
with a much smaller number (about 6 per cent of the 45,000
An ideal strategy development process would have included organizations) worked in the health sector21.
thorough consultation with government, civil society,
This C4D strategy for routine immunization is the result of limited consultation with provincial EPI and communication
specialists, federal EPI officials and some CSOs22. It uses the findings of the KAPB research described in Chapter 4.
Individually and together, using the right mix of diverse communication approaches will contribute to removing, or at
least minimizing, the barriers identified in the KAP studies. As a reminder, the barriers are:
religious leaders, the UN system, the business community and other stakeholders in the well being of Pakistan’s
children. These consultations would have resulted in agreement on the primary, secondary and (if relevant) tertiary
groups of people, or participant groups, to be reached with messages and dialogue. Box 4 discusses provides
information about “participant analysis” that is critical to the success of all short- and long-term communication
programming.
BOX 4 - PARTICIPANT ANALYSIS: KEY TO SUCCESSFUL COMMUNICATION
To achieve results with communication, C4D generally defines three groups of participants for specific approaches.
The primary participants are people whose behaviour is the main indicator of programme success, for example, the
father, mother, grandmother or other caregiver of children to be immunized; school teacher; or government decision
maker.
Secondary participants are people whose behaviour or actions strongly influence the primary participant’s behaviour.
They may come from the cultural and social environment of the primary participants, for example, doctors, friends or
family members, or they may be local or even provincial or national government officials.
Tertiary participants are those whose actions indirectly help or hinder the behaviours of other participants. Tertiary
participants’ actions reflect the broader social, cultural and policy factors that create an enabling environment to
sustain desired behaviour change. These might include parliamentarians, politicians and high level government
officials who make policy and allocate resources, religious leaders, professional associations, or Civil Society
Organizations.
For this strategy, stakeholders in each province – government officials, UNICEF and other UN agencies, civil society
organizations and any others who wish to be involved – should determine the particular approaches that will be
emphasized, how, and over what time frame. For example, advocacy with decision makers may take precedence in
the first year of the strategy, followed by improving the capacity development of healthcare workers.
Given the timing of this strategy’s development and the
with families and communities. It suggests broad strokes for urgency to strengthen routine immunization to reach the
advocacy, behaviour change communication, social change 2018 targets, it is suggested that future consultations
communication and social mobilization, all of which should take place over the February – June period to discuss the
be thought through and planned for at provincial levels. suggestions as presented below with an arrow and to explore
Communication staff in the federal EPI Cell and EOC should ways for participatory monitoring and continuous
dialogue
ensure synergy between the existing RI and polio structures
21. Overview of Civil Society Organizations: Pakistan. Civil Society Briefs, Asian Development Bank, 2009, page 3. 22. More consultation with CSOs
will be important in completing the “Implementation Plans” for 2015-2018.
off and should propose high-level activities to be taken at
at the time of annual review sessions. Plans that are national level that will strengthen provincial and area plans.
developed independently of each other, will rarely achieve
This descriptive part of the communication strategy will be complemented by four-year “Implementation
the collaboration necessary for overcoming barriers. In fact, a joint mid-year review might be also considered.
Plans”, including the “creative” elements, at provincial and area levels. It is suggested that the federal EPI Cell
EIGHT CORE ELEMENTS OF THE STRATEGY communication’s function also complete
an Implementation Plan, taking into consideration the sub-national plans. Contents of planning matrices are being
sent to provinces for inputs. The suggested matrices are included as Annex E. They will be used at provincial, area
and federal levels,
One way to organize the interconnected components of this strategy is to visualize an eight-petal flower. At the centre
of the strategy is a happy, healthy and fully immunized child. Each of the eight petals is integral to the whole flower.
ideally with a joint annual planning process for 2015 kicked
Figure 4 - An Eight-pronged Communication Strategy Flower
Distinctions amongst the flower’s petals may seem blurry at first. After all, changing people’s behaviour and changing
social norms is complicated! The more that people work with these various categories, the more clearly they will
understand both the distinctive characteristics of the strategy and their overlapping nature. They will be able to plan
for a diversity of approaches, rather than focusing on only one or two. Some years, more attention may be given to
capacity development, individual behaviour change and engagement with the media. Other years, more resources
may be dedicated to community change and advocacy with new groups.
Suggestions for each of these blocks, or petals, are made in the remainder of this strategy. For each block, one or
more C4D results are suggested. Defining what result or outcome that communication will be responsible for
achieving is important for monitoring purposes. Having a behavioural outcome as an intermediate result contributing
to the ultimate programme targets will allow communication specialists to demonstrate more clearly the impact of
their efforts.
The barrier or barriers that will be specifically addressed through use of a particular approach or activity are also
suggested.
Using their own data in the KAPB study/ies, an overarching strategy to address the specific barriers of relevance
should be defined at province and area level. Once the barriers to be addressed and the approaches to be used have
been agreed upon, the development of a creative plan for many of the initiatives will begin. At federal level, emphasis
should be given to providing overall direction, guidance and support and to high-level advocacy.
1. PLANNING AND COORDINATION
A functioning, well-oiled coordination and planning structure at all levels is key to reaching the 2018 EPI targets.
Government, UN agency and civil society partners have their own mandate, budget stream and work plan format.
Likewise, the polio and routine immunization programmes
33
are distinct. Yet there is much obvious overlap, so
conscious efforts to tap each other’s resources and to
keep each other informed must be made.
Desired C4D Result:
Decision makers are regularly meeting at all levels for

strategy and monitoring purposes and are sharing
information with all stakeholders.
A Prime Minister’s National Task Force and Provincial

Task Forces exist for the polio eradication effort.
Especially at provincial level, their membership and Terms
of Reference could be reviewed to ensure that routine
immunization services are functional. One of their first
steps would be to undertake a mapping of human
resources available for communication activities, if this has
not already been done.
The National Communication Technical Committee

(NCTC) has been holding joint meetings on EPI and PEI
at the national level. A national Working Group, comprised
of provincial and federal members, could develop a work
plan, possibly short- term, that would lay the foundation for
practical convergence activities. This Working Group could
be given the authority to make specific recommendations
that would promote implementation of the communication
strategy over its full lifetime. Alternatively, an EPI/PEI
Communication Working Group could be established in
one province to pilot the mechanism.
Union Council Eradication Committees and Tehsil Council

Eradication Committees seem to be in place in the
high-risk polio districts. Their functioning should be
ensured and UC Immunization Committees and TC
Immunization Committees established in all districts in all
provinces. Communication Sub-Committees should be
established as well. This may take a year to accomplish,
but with invitations extended to CSOs and local
governance structures, it is doable.
All task forces or committees should meet regularly,

record the meetings and share the minutes with all
stakeholders. Representatives from civil society should be
present at all levels and in the committee membership.
Suggestion: One step that can be taken immediately is

the sharing with each other of 2015 annual workplans by
PEI and EPI communication specialists, and identifying
areas of commonality and joining efforts on production and
dissemination of materials. They should make
recommendations to their managers, who should take
appropriate steps to support collaboration in a few key
activities.
Planning for 2016 and beyond should be conducted jointly, communication materials and training or orientation
using an agreed format / forms, deciding together on a few materials used by COMNet staff, Lady Health Workers
joint activities and determining financial needs. Polio and other healthcare givers, should be reviewed to ensure
programme assets may be able to be tapped for RI. they include messages about all vaccines. Many
polio-specific materials now integrate messages about
Striking the right balance for allocating human and
routine immunization. RI materials should include a
financial resources to communication for routine
sentence about the approaching eradication of polio in
immunization and polio will require much analysis and
Pakistan.
planning.
Suggestion: Materials with the three 2018 EPI targets
At the federal level, the “branding” of routine immunization
should be considered for ongoing advocacy purposes. A
should be undertaken and tools provided to provinces.
simple business-card size reminder may be helpful for
Suggestion: A national campaign to develop a new EPI decision makers. If the decision to develop a pamphlet or
logo or to rejuvenate Teeko should be considered. This card for advocacy purposes is taken, it should be
could be a yearlong effort, inviting provinces to involve all pre-tested with high-level decision makers.
sectors of society to contribute to a slogan, logo and/or
Suggestion: Risk Communication plans should be put in
jingle. There should not be separate RI and polio logos
place. Rumors, misinformation, and the rare but present
and slogans unless they emerge from consultations with
allergic reactions to a vaccine can disrupt any
or requests from communities.
immunization programme, quickly undoing the hard efforts
In 2016, the new or updated Teeko can be launched (see of programme and communication specialists. Having a
below in Social Mobilization). The federal EPI cell should crisis plan in place to be able to respond rapidly and
provide easily adaptable materials for provinces to tailor to positively to adverse events is vital. See Box 5 for steps to
their specific characteristics. take before and during an emergency arises.
Suggestion: In 2015, all immunization (routine and polio)
BOX 5 - RISK COMMUNICATION PLANNING AND

IMPLEMENTATION
1. At federal and provincial levels, BEFORE a crisis happens, the existing committees (where they exist) or
decision
makers should discuss and decide on who will be members of a Crisis Communication
Committee
2. Convene a Crisis Communication Committee, including all implementing

partners.
3. Develop a set of communication messages to address unintended consequences of immunization. Pre-test

the
messages with groups of people for whom they are
intended.
4. Once the messages are finalized, ensure that they are shared with all stakeholders, including CSO
partners.
5. Identify respected spokespersons to deliver the standardized messages to the caregivers and other
identified groups.
6. Conduct briefings with media professionals to ensure they understand

them.
7. Engage local opinion leaders to address the issue(s) in a culturally appropriate manner within their
communities.
8. Conduct briefings with local healthcare providers to explain the issue(s) and to give them “talking points” to
help them
explain to fathers, mothers, families, and other community
members.
9. Monitor and measure the response to the crisis to understand how to make the crisis management plan
more efficient
and effective.
• Determine specific goals and objectives

2. ADVOCACY AND
• Understand which kinds of evidence are available
PARTNERSHIPS (quantitative/qualitative/mixed methods)
The words “advocacy” and “partnerships” are defined in • Develop clear evidence-based messages
several ways and understood in even more ways. • Establish a multi-sector advocacy team
Though a bit long, the following definition of advocacy may
• Evaluate messaging through participatory
be useful for this strategy. It is “a continuous and adaptive
approaches23
process of gathering, organizing and formulating
Desired C4D
information and data into argument, which is then
Results:
communicated to policy-makers through various
interpersonal and mass media communication channels”. 1. Provincial and community leaders and influencers
Through advocacy, we seek to influence policy-makers,are actively showing support for full immunization,
political and social leaders at all levels to develop policy,including development of policy and legislation. 2.
introduce legislation and allocate resources equitably so Influential celebrities are visibly engaged.
that social transformation can happen. We also undertake
With respect to advocacy, Communication Specialists
advocacy with religious leaders, business people, and
should consider the following groups at national, provincial
senior managers in our own organizations and many
and district levels24:
others. C4D is especially attentive to linking the
perspectives and voices of children, women and men from 1. Ministries other than
marginalized groups to upstream policy dialogue. Health
Basically, a “partnership” is a relationship between two or a.Education is especially important, and the cMYP
more people, groups, institutions or other entities to work includes the option for a health module to be introduced.
towards a common goal. One of the underlying concepts This is already happening to some extent, with education
of partnership is that working together will be more authorities and donors supporting application of the
effective than working independently of each other.child-friendly school approach principles. See more
Partners may have different capacities and partnershipssuggestions below in #5, Community and Group Change.
do not always involve financial commitments. For this2. Policy-makers (Parliamentarians), to consider drafting
strategy, “partners” is used to indicate any group involved and introducing legislation
or potentially involved in routine immunization. to:
Applying the following principles will help ensure a.Make health every child’s right (health is not yet
successful advocacy: considered a
• Clearly define the issue citizen’s right in
Pakistan)
b.Make the completed Vaccination Card a prerequisite 6. Private health
for practitioners
enrolment in school 7. Village-level health
3. Media, with a view to evolving a rights-based practitioners
culture in 8. Others who are especially relevant in that province,
the mass media inside or outside the health sector, for example,
4. Medical institutions and members networks (such hakeems, community elders, and family elders
as the
Pakistan Pediatric
23. UNICEF.org website 24. Acknowledgement to the guide, Intensification of Routine Immun
Association) Guideline, Immunization Division, Ministry of Health and Family Welfare, Government of India
5. Pharmacists 35
36
booklets Successful advocacy may lead to partnerships but that
to all school children (see the “Quick Start may not be the goal. The desired result of advocacy or an
Suggestion” to revive the Meena initiative in the Section invitation to be a partner need to be defined and agree.
4 on Individual and Family Behaviour Change).
Suggestions for advocacy and/or partnerships:
• MoNHSRC and Ministry of Federal Education to introduce age-appropriate health modules in all levels in primary
and secondary school curriculum. See more suggestions below in #5, Community and Group Change.
Remember:
C4D makes sure the voices of the community are HEARD upstream. This is an integral part of a good communication
strategy. This means that in meetings, roundtables and discussions, special efforts should be made to ensure that a
community member is present. At the least, quotes or photos should be shared with the decision makers that
demonstrate
• MoNHSRC for a phased increase and strengthened
community support for immunization services. capacity development of LHWs. See #2 below.
Irrespective of the group(s) being advocated with, provinces
• Parliamentarians to pass laws that:
should follow a logical sequence:
1. Make health a basic human right, including for children
2. Make the completed Vaccination Card a prerequisite for
enrolment in school
• Media CEOs: A series of roundtables with media chiefs that would result in an agreed advocacy plan. These could
be scheduled in 2015 with a view to enlisting
1. Understand the immunization status in their
province,district-by-district
2. Create easily understood charts and graphs from
available data
3. Analyze existing policies and decisions among the
identified advocacy group media support for the “RI Slogan” campaign. (In fact, the NEAP 2014 included this activity,
which could not be implemented. It should be reconsidered, if not for
4. Prepare a plan comprising
a. advocacy objectives polio then for RI.)
b. positioning of message
• Mr. Shahid Afridi should be invited to renew his advocacy efforts urging all parents to immunize their children
against all VPDs. He should be asked to identify
c. development of advocacy tools and activities
d. identifying outcome indicators and recruit additional “Immunization Ambassadors” for
5. Assess available resources the four years of this Communication Strategy.
6. Develop a timeline for various advocacy activities
• Province and/or district officials could issue a challenge to businesses to support the attainment
7. Develop compelling messages
of the EPI targets. Small and large business owners
8. Develop advocacy material accordingly could be invited to form an alliance for immunization. They can support or
sponsor a range of activities including printing of materials or purchase of TV and
9. Create networks/partners such as youth groups,
religious/community leaders
DVD machines for public screening of immunization
10. Conduct the advocacy, and document the proceedings. and other health-related videos, or providing Meena
BOX 6 - BARRIERS THAT CAN BE ADDRESSED THROUGH THE ADVOCACY
Barriers that may be addressed through the advocacy activities suggested here are:
1. Concerns of caregivers about safety of Oral Polio Vaccine
2. Low level of knowledge of health care workers regarding VPDs and their prevention
3. Distance, time and cost of travel to health facility on long waiting time there
4. Missing vaccination card in the home
Of course, other barriers may also be addressed, depending on the messaging to and with the selected groups.
Remember: Advocacy and social mobilization are generally conducted simultaneously.
Remember: From the start, involve the IEC unit and the production or supply unit in your entity in the development
and operationalization of the communication strategy
3. CAPACITY DEVELOPMENT
Basic and advanced learning opportunities should be offered at regularly scheduled times and made obligatory for people
involved in ensuring quality health care. In this case, health workers and community-level volunteers and other workers --
including LHWs, CMWs, TBAs/dais, VHCs and others – must be properly equipped with the knowledge and skills needed
for dialoguing with diverse (and sometimes immunization- resistant) caregivers.
Desired C4D Result:
Frontline workers in the health sector (including government, private and CSOs) are regularly participating in
capacity development forums and feel empowered to pass on their knowledge.
The KAP research for both RI and polio indicates unequivocally that healthcare providers are major influencers of
children’s caregivers (see Table 5 and Figure 2 in Chapter 4). Though human resources capacity in the health system is
an operational issue, communication specialists can advocate for a mechanism to ensure progressive training and
refresher sessions for community-level healthcare workers and others. Communication could also advocate for a gradual
increase in the number of LHWs between now and 2018. (This advocacy element is also included above in #1, Planning
and Coordination.) A recognition system could be instituted for LHW role models or “heroes and heroines”, with
performance quality indicators for EPI. A phased approach to regularizing the recruitment, wage levels and training of
LHWs would ideally happen at the federal level.
Well-trained health care workers and community volunteers and social mobilizers will contribute to reducing several of the
barriers identified in the research. This includes increased awareness of VPDs and their prevention; the efficacy and
safety of vaccines; and the importance of vaccination cards. Ongoing capacity development of health care workers and
partners will also reduce caregivers’ misgivings about their knowledge and skills levels.
Simultaneous with human resources recruitment and retention discussions, provinces could undertake a training needs
assessment (if one has not been conducted in the past 3-4 years) to assess skills around:
• Familiarity with and ability to explain VPDs, vaccines and vaccine safety issues such as Adverse Effects Following
Immunization (AEFI) and side effects
• General communication skills including communicating in and with groups
• Inter-personal communication skills, especially for home visits
• Inclusive counseling skills
Religious leaders have been involved in a somewhat uneven manner in the past; they too could be included in the training
needs assessment, using it as a simultaneous opportunity for advocacy. Mullahs and Maulvis will appreciate being asked
what contribution they can make, rather than being requested to make announcements about immunization, education or
other issues. Civil Society Organizations, including those that work with children in areas other than health, should be
consulted about developing a district-wide (or larger) 4 to 5 year plan for capacity development. Space can be negotiated
for a health module to be integrated in CSOs dealing with education, protection, sanitation and hygiene, civic participation
and other issues. Dozens if not hundreds of Facilitator Guides, Participant Manuals, IPC modules and other training
materials have been developed over the years in Pakistan and elsewhere. Indeed, for the introduction of the PCV-10
vaccine in 2012, an IPC module was developed and used at least a few times at provincial level. Too often, manuals are
developed independently of each other, duplicating cost and not benefitting from the inputs of existing or potential
materials and partners. In addition to face-to-face workshops and discussion sessions, all those who play a direct role in
behaviour and social change, including community mobilizers and other targeted groups, should be provided with
up-to-date information and materials on a regular basis. Another possibility is using digital methodologies. Several SMS
projects using cell phone messaging, some of them allowing for “two-way” dialogue, have been developed in the past 10-
15 years in other countries. In Pakistan, voice messaging has been used in the high-risk polio districts. SMS has been
used in literacy programmes by UNESCO and is being considered for use with child protection issues by UNICEF.
Suggestions:
• As a starter, in 2015, the EOC and EPI Cell should review existing materials and plans for new materials with a view to
eliminating duplication and to strengthening the use of proven materials.
• Undertake a training needs assessment at provincial level, coordinated with federal EPI.
• Plan a comprehensive and coordinated approach with and to Mullahs and Maulvis and other religious leaders about what
contributions they can make towards strengthened immunization (and possibly other health and basic services) in their
communities.
• Consult with Civil Society Organizations about developing a district-wide (or larger) 4 to 5 year plan for capacity
development.
• Review existing capacity development materials. Take what is relevant and good; agree on standard modules (or sets of
modules) for specific groups.
• Set in place mechanisms that ensure regular updates are provided to frontline health care providers, religious leaders
and others involved in immunization strengthening.
• Explore the use of SMS for two-way dialogue with health care proiders.
All seven barriers can be addressed over the long-term through comprehensive, coordinated capacity development efforts.
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4. INDIVIDUAL & FAMILY EMPOWERMENT
For most people, deciding to do (or not do) something is the result of many factors. Awareness about an issue and
knowledge about it are often not enough to convince people to change. The opinions or decisions of family or community
members are additional factors. Cost is another issue that is important, as the KAP research revealed. If you factor in a
disability, or a law or other legal requirement, the whole decision-making process becomes complex to understand and
unravel.
This is why this communication strategy emphasizes fostering a supportive environment from among family members,
neighbours, friends and the community. It promotes the creation of opportunities for people to not only hear the messages
about immunization but also to discuss them with trusted sources.
With the KAPB research confirming that interpersonal communication is key to attitude and behaviour change, some
traditional but seldom-used approaches (by development agencies and by government) to allow for dialogue should be
considered.
C4D Results:
1. Caregivers can explain the importance of completing the immunization schedule of their child.
2. Caregivers (mothers, fathers, others) overcome vaccine hesitancy (fear of AEFI and side effects) and express
their intention to vaccinate all their children.
3. Caregivers are reporting improved client-provider interaction.
4. Increased child immunization rates, including of girls and of children with disability, due to strengthened self-
efficacy despite obstacles of cost, distance and waiting time.
These sometimes underutilized communication channels include
wandering poets
storytellers through song (including grandmothers!)
street theatre and mobile theatre troupes
and
mosques, hujras and churches
and
LHWs, CMW, elders, teachers, Girl Guides, Boy Scouts
and
faith healers, hakeems, pharmacists, community elders, and family elders
Of course, all these groups need to be fully equipped when

they head out to undertake their responsibilities. They require training, as discussed above, and materials. Materials for
use in behaviour change communication may include:
• User guides for communication materials
• Flip chart with images for participants on the front and discussion points on the back for the LHW or other user
• Flash cards
• Games
• Comic strips
• Books
• Videos
• Information sheets for their own use, with immunization messages and additional information; when parents should
return next; the importance of the Vaccination Card; what to do in case of side effects; how to congratulate the parents
• Information leaflet to leave with the household or discussion group participants
• Cap, apron or other clothing item to identify the LHW, COMNet or other volunteer
• Clipboard with essential forms and adequate paper for note-taking
Creative materials should be developed and produced by professionals who understand audience segmentation, pre-
testing and a tailored approach. As fathers are the decision makers in many families, special materials and careful
selection of communication channels will be needed.
Quick-start Suggestion: Revive the Meena series, starting with “Baby Rani’s Four Visits”. The little girl Meena and her
brother Raju were used successfully for several years in Pakistan. She is alive and well in Disaster Response, helping
communities be more prepared in case of flood or earthquake, but has almost disappeared from view in some sectors. The
“Baby Rani” book could be easily updated and disseminated by LHWs and in schools.
Suggestions:
• Revive Facts for Life (FFL), starting with the chapter on immunization. This book has been translated into Urdu and may
not be being used as effectively as it could. Enlisting the support of the private sector and civil society organizations, this
popular booklet could be updated and adapted at provincial levels, with a special section on the push for achievement of
the three EPI targets by 2018. Many spin-off creative materials around the world have been based on Facts for Life – flip
charts, leaflets, videos and others.
• Explore possibilities for partnerships with new and existing CSO partners, especially those that work in hard-to-reach
areas where government facilities are minimal or non-existent. The Aga Khan Foundation’s Rural Support Programme
could be examined for possible replication and expansion to include routine immunization. Some CSOs involved with
health education and communication include HANDS, HELP, NRSP, Aagahi, Friends Foundation, Awaz, The Health
Foundation and Save the Children and many others.
With the IPV scheduled for introduction nationally in 2015 and OPV to be phased out by 2016, clear messages should be
developed about OPV and IPV. In fact, creative messaging around repeated doses of OPV has been very challenging.
Ideally, new messages would be developed WITH communities (or within districts) that have been identified as high-risk
and have residents who are resistant. The most relevant channels should be used to convey the messages and to
dialogue with caretakers.
The Annex C matrix shows some of the key characteristics in terms of communication channels in Pakistan. It explains
how much or little dialogue is inherent in the channel, what its reach generally is, how complex the messaging can be, and
whether it is high or low cost to use. Using the polio and RI research from 2014, it is clear that more resources need to be
invested in people “closer to the ground,” including LHWs and other health care providers.
While fraught with challenges, strengthened cross- border collaboration with the government, civil society organizations
and the UN system in Afghanistan might also be strengthened. The two countries are co-dependent with respect to polio
eradication. The 2014 FATA polio work plan contained an unbudgeted line item for quarterly cross-border meetings and
branding of vaccination points. Communication specialists on both sides of the border could also organize discussion
sessions at specific transit points two or three times annually, ensuring dissemination of leaflets or other appropriate
communication tools that have been developed in collaboration with traders, commuting families and others who pass
back and forth between the two countries.
Barriers that may be addressed through activities supporting Individual and Family Empowerment are
• Low awareness level amongst caregivers and healthcare

providers regarding vaccine-preventable diseases and their risks
• Concerns of caregivers about the safety of Oral Polio Vaccine
• Belief in and use of local remedies for prevention and treatment
• Low knowledge and awareness of healthcare workers regarding VPDs and their prevention
• Distance, time and cost of travel to health facility and long waiting time there
• Missing vaccination card in the home
5. COMMUNITY & GROUP CHANGE (SOCIAL CHANGE)

While many of the same techniques and materials used for individual and family-level change are relevant for
community-level change, some important differences exist. First, groups of people outside the household are considered:
the local business community, education system (including administrators), transportation and/or energy infrastructures,
religious network and political leadership, amongst others. The main idea is to influence key groups to become allies.
Desired C4D Results:
1. Community members are participating in advocacy and/or mass events organized to demonstrate support for
immunization/children’s health.
2. Women, people with disabilities, adolescents, and different ethnic and religious groups are participating in
dialogue around immunization.
3. Children enrolled in school are receiving education

about immunization & other health issues.
Suggestion:
One idea that emerged from consultations was to make the completion of the vaccination schedule a reason to celebrate
the parents’ achievement. UCs could track the completion of full immunization and, in cooperation with local businesses,
make an award to parents or to villages, during a Mother/Child Health Week or other regularly scheduled gather. This
would be another use of the “recognition” or “award” mentioned in #3 above.
The cMYP included the strategy of including routine immunization “in the school curriculum”. Discussions and steps to
integrate health modules into the primary school curriculums could be initiated in 2015 by the MoNHSRC and Ministry of
Federal Education and Professional Training. This would provide an ideal opportunity to ensure immunization information
for all children enrolled in school and, if an integrated horizontal approach is taken, introduce increasingly complex but
always age-appropriate content into the education system. At provincial level, the Provincial Education Departments,
should be discussing the same.
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40
caregivers Substantial work to introduce the globally recognized Child-
to immunize their children. Mass media will Friendly School Standards is underway. The health sector
continue to be needed, but perhaps more as back-up or should work closely with the education sector to strengthen
reinforcement of messages and dialogue at provincial and existing modules on hygiene and water-borne diseases in
the
district levels between healthcare workers and community social studies curriculum. With many of the same
international
members. bilateral agencies and organizations investing in the health and education sectors, the cMYP’s proposal to
develop
Desired C4D Results:
a new health module or strengthen existing ones could be
1. Respondents to surveys, who will have watched or taken forward by initiating cross-sectoral discussions. By
heard about the radio or TV drama, are expressing their 2 016, initial modules could be available for one or two
grade
support of and demand for immunization. levels, and children themselves could be equipped with the knowledge
and skills to take messages and materials home to their parents.
2. Major media outlets are routinely covering immunization issues in a positive manner.
Suggestions:
As noted above in #2 Advocacy and Partnerships, TV, radio and newspapers are communication channels that
• Engage community- and district-level groups for the bi-
can contribute to increased immunization. One idea from a annual Mother/Child Health Weeks, Family Health Days
provincial consultation was to invite local or national media and World Immunization Week. Make these community-
to special briefings on routine immunization. If national or district-level events to be looked forward to, with a
media is invited, coordination with national-level structures booth with TV to show videos and services like blood
should be ensured. The end outcome of 2-3 years’ regular pressure.
briefings would be increased and positive coverage by media
• Influence existing community caregiver/mothers
of immunization issues.
groups (or form new ones) to become role models (or
Suggestion: “positive deviants”). During a mother’s group meeting facilitated by an LHW or other health care worker
or volunteer, a group of mothers could be identified who have completed their children’s immunization schedules
(plus other integrated MNCHN practices). Then, the health status of the children of these mothers would be
compared with those whose immunizations are not met. They then engage in discussion based on kids’ immunization
and health status.
An Entertainment Education (EE) partnership could be considered. EE programmes have been successful in other
countries for many years, on subjects ranging from domestic abuse to HIV & AIDS to early marriage. They integrate
subtle (and not-so-subtle) messages into story lines and, when well conceived, are emotional and intellectual
experiences that stimulate the viewer or listener to discuss the story with family members, friends and colleagues.
Under this scheme, a new 10- or 12-episode radio or television series could be The 2013 document “Optimizing the
contribution of the Polio
initiated or producers of existing programmes convinced to Eradication Initiative to broader immunization and disease
integrate immunization messaging into ongoing episodes. control goals in Pakistan” suggested that the 2,200 “Polio
EE programmes are expensive, so if further analysis reveals COMNet” staff establish “community coalitions”
consisting
that it should be considered in Pakistan, measures must be of community based bodies, religious leaders, key
influencers
taken to include online streaming, cassettes, DVDs or other and health care providers (Lady Health Worker, Lady
Health
methods for dissemination in the remotest communities. Visitor, Lady Health Supervisor, Vaccinator, social mobilizer
Discriminatory stereotyping of characters should be avoided. or a medical officer)25.
WARNING: Of course, children and adolescents who are in school or in an organized group such as religious
classes, Girl Guides or Boy Scouts or other, are also important potential mobilizers in their communities. Children as
“agents of change” does not seem to be a concept currently in wide practice in Pakistan,
These shows can be expensive, so unless specific research indicates that this would be effective in convincing the
desired groups to change their behaviour or practices, it should not be undertaken.
so there is wide open space for creativity in this area. The
Depending on the number of episodes and complexity of the B oy Scouts, Girl Guides and other organizations for
children
storylines (which will depend on the intended audience(s), a a nd youth have participated in mobilization activities in
the
good EE programme could address all seven barriers. p ast; their involvement should be resurrected.
6. MEDIA ENTERTAINMENT EDUCATION
7. SOCIAL MOBILIZATION
Though it is similar to community and group change While broad-based mass media messages for general
communication, social mobilization has a more public aspect awareness have been broadcast regularly in past years,
to it. Members of religious, civic and business groups and the 2014 KAP research indicates across the board that
community networks come together in a coordinated way to interpersonal communication is more effective in
convincing
reach specific groups of people with planned messages. In this
25. Optimizing document, page 8.
strategy, they are suggested to be engaged in complementary, inter-related efforts to convince their own neighbours and
friends to “come on board” with immunization, on the one hand, and on the other, to convince political leaders and other
leaders to ensure that immunization services are available and accessible to all caregivers.
Desired C4D Result:
Communities are expressing their support for improved children’s well being.
Other communication channels that contribute to social mobilization are:
• Transit vehicles: Busses, rikshas, trucks, taxis
• SMS messages
• Local radio
• Public Services Messages in cinemas and on TV
• DVDs on laptops for public showings
• Banners and billboards
Effective social mobilization and interpersonal communication go hand in hand. Social mobilization depends to a large
extent on interpersonal communication (IPC), and is supported by mass media and other communication channels. This
strategy has not highlighted social media, for example. Facebook, Twitter, WhatsApp and other networks are already
catalysts for social movements and should be tapped to mobilize large groups of people around immunization, especially
as momentum towards 2018 builds.
Of course, all social mobilization activities should be part of an overall provincial communication plan. Mobilizers may be
users of social media as noted above, and they can also be puppet or theatre groups; wandering poets; influential people
at provincial, UC and district levels; Boy Scouts and Girl Guides; media outlets; teachers; and many others. Mobilizers
should receive training on delivering key messages and be provided with materials such as leaflets, stories, songs,
slogans and testimonials from respected community members. There should be practice sessions for mobilizers prior to
the events like Mother and Child Health Week and World Immunization Week.
Suggestion:
If a national campaign to develop a new EPI logo and slogan or to rejuvenate Teeko is launched, a competition amongst
or within provinces could be organized. Criteria and rules would be established, with recognition and awards to the winning
entities or individuals.
Social mobilization may be effective as an advocacy tool, advocating for a guarantee of ongoing capacity building of
vaccines and vaccinators, or for parents to ensure they maintain their children’s vaccination cards. Or, a province may
wish to generate and support social mobilization to reduce other barriers.
8. MONITORING FOR COMMUNICATION RESULTS
Monitoring for the contributions that communication makes to reach overall programme goals is always a challenge.
Communication practitioners understand the importance of monitoring so that that attribution can be given to
communication. Solid monitoring also furthers the learning process so that adjustments in the approaches can be made.
Progress has been made in the past few years in defining behavioural or social results in ways that can be measured.
Desired C4D Result:
Communities are monitored for immunization-related behaviour. R outine and polio monitoring are tough enough for
the vaccinators and health system staff. While it may seem simple enough to procure, distribute and give injections or
drops, the challenges are multifaceted. Monitoring for changes in the knowledge, the attitudes and the practices is equally
fraught with complexity. While a person’s knowledge might be seen as more easily measured than his or her internal
attitudes or more visible practices, changes in all three elements of behaviour and social change communication – that is,
in knowledge, in attitudes and practices (of individuals and of groups) -- usually take a longer time to manifest themselves.
The aspect of attribution is also complicated. Was it the supply of vaccines that contributed to a higher immunization rate
or was it an attitudinal shift by caregivers? Since top decision makers everywhere want to show results, usually in the form
of quarterly, biannual or yearly statistics, communicators are pressed to demonstrate quickly the effectiveness of
announcements made through mosque loudspeakers or of discussion sessions with mothers or fathers. Nonetheless,
agreeing on communication, or C4D, results and on indicators to measure them by, is critical. This eighth “petal” or
component of the C4D RI communication strategy offers draft indicators and suggestions for monitoring mechanisms.
Depending on what activities are included in the province, area and federal implementation plans, the below indicators
could be selected and refined.
• % (or proportion) of legislators / policy makers / village leaders who are publicly supportive of all vaccines and full
vaccination
• % of financial and human resources available for communication activities
• Proportion of local media that regularly promotes vaccination in a positive way
• % of caregivers who are aware of the routine immunization schedule AND who take the necessary steps (or dedicate the
necessary resources) to have all their children fully vaccinated
• % of the population defined (by UC, district, or province) (and disaggregated by residence, wealth quintile, age,
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• sex, ethnic/religious/minority background, and disability
Outcome Mapping status) believe most people around them get their children fully vaccinated
• Most Significant Change (MSC)
• Proportion of communities that received opportunity to dialogue with a healthcare provider in the past 3 months
Quantitative methods that could be discussed for applicability include surveys and Focus Group Discussions.
Because this is not a “how-to” manual and to keep the strategy less
• Proportion of population defined (by UC, district,
intimidating, descriptions of these qualitative and quantitative or province) (and disaggregated by wealth quintile,
methodologies are not included. If that is something that residence, age, sex, ethnic/religious/minority
would be useful in Pakistan, they can be provided. background, and disability status) feel they can submit feedback
and complaint to the service provider and get timely responses regarding [the specific issue].
Tools that will be used by staff, LHWs, volunteers or others to conduct monitoring activities should be then
developed. Matrix 5 in the set of matrices is a very simple progress
• Proportion of population defined (by UC, district,
report that can be adapted for use. Better yet, a matrix could or province) (and disaggregated by wealth quintile,
be designed that combines elements from the RI monitoring residence, age, sex, ethnic/religious/minority
checklist used in Punjab, the COMNet report (which is done background and disability status) who participated in a
weekly and might be too frequent) and a “direct observation” public gathering in support of vaccination
checklist that is sometimes used in qualitative research and
• In communication, process is important to achieving outcomes. You might want to have a process indicator, such as
“% of women participating in a community
monitoring. Space should always be provided for recording any unintended consequences of programme activities
and of unanticipated events.
meeting about access to healthcare for their child who
Create easy-to-use reporting forms that are mindful of the felt that their opinion contributed to a solution to the
time it will take a supervisor to read the monitoring forms problem.”
and to complete the reporting form. A process for reviewing
These draft indicators and others are provided in Matrix 4 of the Implementation Plan matrices. It is critical that at
provincial level, EPI, PEI programme and communication staff from Government, UN agencies and CSOs agree on
what
monitoring reports, discussing them with staff, partners, and other stakeholders and delegating tasks to address any
issues that require immediate attention and issues that can be addressed at a later time.
changes in individuals and communities they would like to see happen.
RESOURCE REQUIREMENTS AND FUNDING
Then, a monitoring plan should be developed, with agreement
Last but not least is the sensitive issue of financial and on the information that will be collected from which person or
human resources. people, by whom, when and at what cost.
Provision was made in the EPI Comprehensive Multi-Year Remember: Be mindful of ethical practices of ensuring the
Strategy 2014-2018 for 1 per cent, or roughly $20 million, of privacy and security of information from participants.
the estimated $2.6 billion foreseen for routine immunization,
Remember: It took several years for the health system to decline and for expectations of people to likewise be lower.
It will take time to empower caregivers to advocate for
should be allocated for “advocacy and communication”. This is a welcome acknowledgement that demand generation
and communication play a role in achieving the three targets.
immunization and other basic services.
The 6-7 January Consultation Meeting referred to at the
Qualitative data is now recognized as valid, when it has been rigorously collected and analysed. Many organizations
and governments still find it difficult to allocate adequate resources to set communication monitoring mechanisms in
beginning of Chapter 5 recommended that this be doubled. A meeting to discuss HSS was being held
simultaneously, so the opportunity may have been missed for 2015. This should be explored.
place, whether they are qualitatively or quantitatively oriented.
Likewise, suggestions were made to ensure that One, two or more of the following recognized qualitative
communication is provided for in the new PC126. methodologies could be introduced:
But, these suggestions were made without any sort of costing
• Participatory Rural/Urban Appraisal (PRA) and
exercise that would estimate the total needs to implement all Participatory Learning and Action (PLA)
or part of the suggestions made in this strategy. Sometimes,
• Focus Group Discussions (which can also be quantitative – see below)
a lot can be accomplished with a surprisingly low financial allocation. Generally, communication is underfunded even
as miracles are expected and communication professionals are
• Community Information Boards
criticized for not showing results.
• Case Study
Until provinces, areas and the federal EPI cell go through a planning process and agree on their overall approaches
26. The PC (Planning Commission) is a financial and public policy development institution of the federal Government, which is situated under the
Ministry of Planning and
Development. The PC-1 is the form for official budget planning and approval.
caregivers and define the communication approaches and activities,
for immunization and to support government materials, capacity development, mobilization and other
efforts is the focus of this strategy. With strong evidence now needs, the suggested $40 million may be high or it may
be
in place that identified seven knowledge, attitude or practice low.
barriers to immunization, the strategy has identified effective
Discussions should take place about the possibility of deploying some of the financial and human polio resources to
routine immunization activities in any of the above components. Some polio materials now include RI messaging, but
more can be done to join forces with respect to advocacy for EPI system strengthening, individual and family
empowerment, group and community engagement for
communication channels and approaches. Several activities are suggested, including the launch of a national
campaign to revitalize Teeko or develop a new logo and slogan; rejuvenate the Meena series; ensure health modules
are integrated into the school system at all grade levels; and ensure an integrated and comprehensive capacity
development strategy is in place for health care providers and CSOs working on the ground.
RI and social mobilization for RI.
Above all, perhaps, shifts in attitudes and practices within our
This strategy also suggests that more resources be allocated to community-level approaches.
own organizations may be required. With separate structures for polio and routine firmly in place, it will take effort to
conduct joint review and planning meetings. Yet they must DISCUSSION AND
RECOMMENDATIONS
begin in 2015. A shift of resources from mass media (TV and radio) to community-level, dialogic communication is
This document has presented a brief and perhaps simplistic overview of one small but important aspect – childhood
immunization – of the highly complex environment in which
in order, given caregiver reliance on health care providers, family and friends for their information about
immunization. That will be difficult yet the process must start. Pakistani citizens find themselves. 2014 was a rough
year, especially for hundreds of children, 300 of whom contracted polio and dozens others killed or injured in various
incidents throughout the country. All injury, disability and death to these children could have been prevented. This
strategy presents ideas for using communication to prevent diseases that should no longer threaten Pakistani
children with disability or death.
Given the urgency to strengthen routine immunization to reach the 2018 targets, analysis of existing 2015 work plans
and budgets should be made. Consultations at provincial level should be scheduled between February and June to
discuss the analysis and the suggestions in this strategy. Implementation plans for the communication strategy
should be fleshed out by June, perhaps for discussion during mid- year review meetings. These are measles,
diphtheria, tetanus, pertussis, polio, pneumonia, tuberculosis, meningitis, hepatitis B and Hib meningitis. Vaccination
prevents children from catching these diseases, yet almost half of all children in Pakistan remain partially or
unimmunized. Three of these diseases are targeted for eradication, elimination or reduction by the end of 2018 –
polio, tetanus and measles. These targets are achievable but will require concerted efforts by government, in
partnership with business, civil society and international organizations.
This strategy should be seen as a menu of options from which provinces, based on their review of the KAPB studies,
may select. No doubt they have additional strategies and initiatives that have been successful; these should continue.
Table 12 provides a quick overview of realistic actions that can be taken in 2015 and milestones to aim for in the
coming four years. Pakistan once achieved 86 per cent childhood immunization27. Those children of the 1980s are
now parents and evengrandparents by now. Their children and grandchildren deserve the same. Using
communication to build support amongst children’s
TABLE 11 - MILESTONES FROM 2015 THROUGH 2018 FOR INCREASING
ROUTINE IMMUNIZATION
1st half of year 2nd half of year
2015
Establish or strengthen Communication Committees
Review prospects for updating / reviving Meena; if at all levels, set info sharing & planning mechanisms
funding available, reprint and distribute Rani booklet in place MoHNSRC and Min. of Federal Education begin dis-
cussions for long-term health curriculum throughout primary school years (using Child-Friendly School principles)
Mobilize CSOs for 3-year campaign to reach targets
Plan campaign for introduction of IPV; prep on-the- ground folks for its launch
Implement IPV campaign
27. EPI Financial Sustainability Plan 2003-2012.
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Dialogue with appropriate authorities about long-term capacity development of LHWs and other vaccinators
Training Needs Assessment for LHWs, unless one exists (Ck w/Nat’l Institute of Health) Get Shahid Afridi to pledge
3-4 more Ambassadors by year’s end
Develop group-specific materials for agreed approaches to: religious leaders; politicos; health care workers Hold joint
EPI/PEI mid-year review, include risk communications discussion
Risk communications strategy in place
Continue individual & family empowerment and community & group engagement activities
Joint EPI/PEI annual planning process
Advocate at highest level for increased resources to EPI; businesses approached for support
Gov’t allocation to EPI increased.
1st half of year 2nd half of year
2016
Launch the Teeko contest with the new Ambassa- dors; CSOs fully on board
Provide update to the public about the Teeko contest
Business alliance for EPI launched New standardized modules for all healthcare workers
at community level finalized, disseminated to gov’t and CSO entities and in use Religious leaders in all provinces
commit to regular discussions about immunization
SMS or voice messaging mechanisms in place
New Meena episodes planned Meena materials available Media roundtables and radio talk shows take place CSOs,
businesses Explore potential adaptation or reprint of Facts for Life Integrate Facts for Life into plans for 2017 and
2018 Continue individual & family empowerment and community & group engagement activities
No cases of polio – Make a media blitz and school celebrations 1st half of year 2nd half of year
2017
Continue individual & family empowerment and community & group engagement activities
Legislation passed requiring prrof of full immunization for entry to school Individually and together, celebrity and other
influen- tials are speaking on behalf of immunization
No cases of polio – Make a media blitz and school celebrations 1st half of year 2nd half of year
2018
Continue individual & family empowerment and community & group engagement activities 2015
Social mobilization builds for December celebrations
Advocacy continues Rapid assessment to determine how knowledge, atti-
tudes and behaviours have changed over past 3 years Polio eradication declared; elimination of MNT; target for
measles reduction met – National Celebration
Bibliography 06

“Childhood Immunization in Pakistan. Research and Development Solutions”. Policy Briefs Series No. 3, USAID. February
2012.
Common country programme document for Pakistan, 2013- 2017. DP/FPA/OPS-ICEF-WFP/DCCP/2012/PAK/1, 25 June
2012.
“Communication Strategy for the Introduction of Pneumococcal Vaccine (PCV) and Strengthening Routine Immunization in
Pakistan”, Consultancy Mission Report. Teresa Stuart Guida, Consultant, UNICEF, Pakistan Country Office. For the
periods 2 August – 4 September 2012 and 6 November – 6 December 2012.
Communicating Good Nutrition in Timor-Lese: A Communication for Development Strategy, Toward Achieving the Goals
of the National Nutrition Strategy 2014-2019, Teresa Stuart Guida, Supported by UNICEF and DFAT- Government of
Australia, draft August 2014.
Comprehensive Multi-Year Plan 2014-2018: Expanded Program on Immunization. Ministry of National Health Services,
Regulation and Coordination, Government of Pakistan, 2014.
Equitable and Sustainable Development of Provincial Health Systems in Pakistan: Health Policy and Technical Guidance.
Ministry of Inter-Provincial Coordination, July 2012.
“Equitable and Sustainable Development of Provincial Health Systems in Pakistan, Health Policy and Technical Guidance,
integrated communication strategy action plan, PCV 10”. Draft, July 2012.
“Expanded Programme on Immunization Financial Sustainability Plan, 2003-2012”. Federal EPI/CDD Cell, National
Institute of Health, Ministry of Health, Government of Pakistan. Islamabad. November 2003.
“The Expanded Program on Immunization in Pakistan: Recommendations for improving performance”. Tayyeb Masud and
Kumari Vinodhani Navaratne, Health, Nutrition and Population Family, The World Bank, April 2012.
Handover Notes with Recommendations. Teresa Guida Stewart, C4D Consultant for PCV10 Introduction in Pakistan, 29
August 2012.
“Health and the 18th Amendment: Retaining national functions in devolution”. Dr. Sania Nishar, HeartFile, 2011 or 2012,
www.heartfile.org.
“Immunization in Pakistan, Briefing Paper #37”. Pakistan Institute of Legislative Development and Transparency (PILDAT),
May 2010.
“Implementing National MNCH Communication Strategy: Phase I, Developing Implementation and Monitoring Plans”.
Produced by Technical Resource Facility (TRF), 2010.
Intensification of Routine Immunization: Communication Operational and Technical Guideline. Immunization Division,
Ministry of Health and Family Welfare, Government of India, 2012.
KAPB Research: A study to identify drivers of inequities and barriers to access and utilization of immunization services for
improved immunization coverage and outcomes in Pakistan, conducted for the Government of Pakistan and UNICEF by
Oasis Insights, Ltd, 2014.
“National Communication for Development Strategy, Routine Immunization” Draft. Ameena Kamaal, Consultant.
November 2014.
National EPI Policy and Strategic Guideline: Pakistan, Draft, 2014.
“Optimizing the contribution of the Polio Eradication Initiative to broader immunization and disease control goals in
Pakistan”. Uncredited and unpublished, 2013.
Overview of Civil Society Organizations: Pakistan. Civil Society Briefs, Asian Development Bank, 2009.
Pakistan Communication Strategy for HIV/AIDS (Know Positive: Strengthening AIDS Response through Strategic
Communications), 2013-2015. National AIDS Control Program, Provincial AIDS Control Program/Punjab; Sindh AIDS
Control Program; AIDS Control Program/Balochistan; KPK; UNICEF and UNAIDS.
Pakistan Demographic and Health Survey, 2012-13. National Institute of Population Studies, Islamabad, December 2013.
“Pakistan and Its Neighbours: A Disaster Unfolding,” Section 1 of Report #10 of the Independent Monitoring Board of the
Global Polio Eradication Initiative. October 2014.
Pakistan: Media and Telecoms Landscape Guide. Infoasaid, June 2012.
Polio Eradication & Endgame Strategic Plan 2013-2018. World Health Organization, 2013.
“Poverty and Social Impact Analysis of Expanded Program on Immunization in Pakistan”, Working Paper No. 143.
Authors: Vaqar Ahmed and Sofia Ahmed, Sustainable Development Policy Institute for UNDP, June 2014.
“Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization
card and maternal education”. Usman, Hussain R. et al, National Institutes of Health, published in Tropical Medicine and
International Health, March 2011; 16(3): 334- 342.
“Reaching the Unreached: Communication for Immunization to Achieve the GVAP Goals”, Draft. Christine McNab,
Consultant, UNICEF Health Section, NYHQs, November 2014.
45
“Regional Communication Strategy Development Guide for Newborn Care and the Prevention and Control of Childhood
Pneumonia and Diarrhoea in East Asia and the Pacific Region, Corinne Shefner-Rogers, commissioned by C4D Section,
Programme Division, UNICEF, New York, 2013.
“Understanding Barriers to Immunization in Pakistan, Volume 1: Issues Related to Programme Management and Service
Delivery Knowledge, Perceptions and Views of Mothers and Fathers about Service Delivery”, Household Survey. Tauseef
Ahmed, Arjumand and Associates, for UNICEF Pakistan CO, 2009.
“Understanding Barriers to Immunization in Pakistan, Volume 2: Quantitative Component”, Household Survey. Tauseef
Ahmed, Arjumand and Associates, for UNICEF Pakistan CO, 2009.
World Development Report 2015: Mind, Society and Behaviour. The International Bank for Reconstruction and
Development/The World Bank, December 2014.
Draft matrices suggested for launch of PCV in Pakistan, 2012. These were adapted for use in this Communication
Strategy.
Matrix 1. Communication Action Plan: Activities, Participant Groups, Communication Materials and Agency
Matrix 2. Communication Budget Plan: 2012 – 2015 FOR Federal Level, 4 Provinces and 3 Areas
Matrix 3. Template for Reporting Progress on Provincial Communication and Social Mobilization Plan Implementation (with
indicative activities and channels)
(Matrix 4.) Template for Documenting C4D Good Practices and Lessons Learned from PCV Introduction and Rollout in
Pakistan
Matrix 5. Process Criteria for C4D Planning, Implementation and Monitoring in the Introduction of New Vaccines and RI
Strengthening in Pakistan
Annexes Annex A. Theories of Change:

Socio-Ecological Model and Health Belief Model
The SEM and the Health Belief Model have similarities.
likely to be successful and sustained when communication The major point is that all planning for behaviour and
addresses the multiple levels of influence in a synergistic social change should be founded on an agreed theory of
manner applying the corresponding communication change. The TOC helps guide the types of interventions and
approaches (behaviour change communication, community communication approaches that should be most effective.
mobilization, social mobilization and advocacy) appropriate at each ecological level. Figure 1 shows the concept of
the 1. THE SOCIO-ECOLOGICAL MODEL
SEM.
This strategy uses the Socio-Ecological Model (SEM) as its underlying theoretical framework. Dozens if not hundreds
of theories of change (TOC) have been formulated over the years by academics, civil society organizations, UN
agencies, bilateral institutions, businesses and others. These frameworks attempt to describe why and how
individuals, groups of people, institutions and systems change or do not
SEM principles are line with rights-based and equity- focused principles that guide participatory social change
communication. Communication for Development, at heart, practices the principles of inclusion, participation and
empowerment for everyone, including boy and girl children and adolescents, women and men. These are highlighted
in the boxes that follow Figure 1 on the next page. change over time. They are useful in explaining “cause and effect”,
sometimes in overly simplistic ways and other times through highly complex descriptions. Most TOCs have merit, so
it is often the decision of individuals in a certain place at a certain time to apply a specific set of principles and
methodologies.
28 29
In this strategy, the SEM is proposed as a foundational framework . For mothers, fathers, grandparents and other
caregivers, as well as for healthcare workers at all levels, to feel strengthened commitment to having fully immunized
children, we need to understand and take into account their entire social environment, or ecological, system. This
includes the interconnected influences of family, peers, friends and neighbours, community, culture and policies and
legislation. Positive changes in an individual’s behaviour, values, attitudes and other predispositions are shaped by
influences from a supportive environment.
Figure 1. The Socio-Ecological Model of Communication for Behaviour and social change Influencing positive change
in vaccination practices and creating social change around healthy behaviours are more
Principle 1. Inclusion As a key human rights principle, inclusion and non-discrimination based on gender, ethnicity,
religion, ability, socio-economic and/or HIV status are embedded in all interventions and processes proposed by any
C4D strategy. Emphasis is placed on ensuring that individuals and groups, particularly the poor, excluded, vulnerable
and disadvantaged are treated equally; are able to access information; participate in decision-making; voice their
opinions; make informed choices; and are able to collectively transform choices into desired actions and outcomes for
their greater good. For instance, healthcare providers such as Lady Health Workers, and other communicators such
as the polio sector’s COMNet staff, will be trained and sensitized to become role models in practicing inclusive
behaviours. Teachers will support and encourage marginalized children to complete schooling. Children will be
motivated to not discriminate against their peers based on gender, ethnicity, ability or socio-economic status.
28. See: McLeroy, K.R. Bebeau, D. Steckler, A. and K. Glanz (1988). An ecological perspective on health promotion programs. Health Education
Quarterly, (15), 351-377. 29. Credit for much of this section goes to Dr. Theresa Stuart, PhD, whose work on a nutrition communication strategy in East
Timor was used.
47
Social norms are also addressed in this strategy. Social norms exist when behaviour is practiced across a community or
social system by almost everybody. The behaviour is normally rooted in traditions and has been practiced for generations,
for example, using home-based remedies to prevent disease. The norm depends upon an individual’s own beliefs as well
as beliefs about the practice by others who matter to the individual, such as family members and friends. It is based on
social expectations and this makes the practice interdependent.
Usually norms prevail as individuals see others in their social network practice a behaviour and hence also practice it.
They are thus conforming to their community or because there may be formal or informal sanctions if they do not practice
a widely followed behaviour. Harmful norms are abandoned when enough people see other individuals in their social
network abandoning the practice, thereby changing the perception of social expectations and sanctions. For example, this
may be true in overcoming the use of traditional methods to prevent vaccine-preventable childhood diseases.
Communication Approaches and the SEM
A combination of four interrelated and interdependent approaches are used to reach, engage, empower and influence
individuals and communities to achieve the desired changes in behaviours and social practices. These communication
approaches are
• advocacy;
• interpersonal communication (IPC) / individual and family empowerment;
• community mobilization / community and group engagement; and
• social mobilization.
Principle 2. Participation Participation in C4D involves communities in understanding and assessing their
socio-cultural and communicative realities and in taking actions to improve their lives and environment.
Participation is foundational to C4D efforts as there is an increasing push for communication interventions
to be developed for, by and with women, children and communities, a trend reinforced by community
engagement methods, interactive media and digital technolo- gies that enable user-generated content and
two-way communication. Over time, efforts will be made to engage and enable girls and women, men and
boys and community groups, with leadership of their Union Councils, to participate in activities that promote
and model good health practices, thus promoting their own wellbeing and that of their families and
communities.
Principle 3. Empowerment Empowerment may be seen as the capacity of individuals and groups,
particularly the poor, excluded, vulnerable and disadvantaged, to participate in decision-making, voice their
opinions, make informed choices and to collectively transform those choices into desired actions and
positive outcomes for their greater good. In Pakistan, empowering members of socio-economic classes D
and E to advocate for their rights to vaccination (amongst other rights) could lead to strengthening of the
overall health system.
Figure 2 shows how these four approaches can be applied at different levels of the SEM framework to reach the
defined goals.
Behaviour and Social Change Outcomes
by SEM Level
INDIVIDUAL/HOUSEHOLD Interpersonal/Behaviour Change Comm
COMMUNITY Community Engagement &
Knowledge/ Awareness Attitudes Skills
Beliefs/values Perceived benefits Perceived barriers
Capacity
Self--efficacy
Figure 2 - Behaviour and Change Outcomes by SEM Level30

2. HEALTH BELIEF MODEL
30. Acknowledgement to: Communicating Good Nutrition in Timor-Lese: A Communication for Development Strategy, Teresa Stuart Guida,
Supported by UNICEF and DFAT/Government of Australia, draft August 2014.
INSTITUTIONAL Advocacy Mobilization
Social Mobilization
Partnerships Collaboration Resource complementation Institutional
capacity
POLICY Advocacy
Inclusion Participation Collective action Social
norms Efficacy Empowerment Community capacity
Political commitment Legislation Policies Implementing
guidelines Funding Budget allocation Governance
Cross--cutting Social Change Outcomes: Inclusion

Participation
Social Norms Empowerment
The Health Belief Model was used as the conceptual framework for the national KAPB research on Routine
Immunization. The model is a predictor of preventive health behaviour. This model allows the individual to set his or
her
own targets for behaviour change, based on perceived levels of susceptibility to disease, severity of the disease and
the benefits of taking a particular course of action.
49
50
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
Perceived Susceptability to Disease “X”
Perceived Seriousness (Severity) of Disease “X”
Demographic variables
Perceived (age, sex, race,
benefits of preventive action
ethnicity, etc.)
minus
Sociopsychological variables
Perceived barriers to preventive action
Perceived Threat of Disease “X”
Likelihood of Taking Recommended Preventive Health Action
Cues to Action Mass media campaigns Advice from others Reminder postcard from physician/dentist Illness of
family member or friend Newspaper or magazine article
Figure 3 - Health Belief Model
Annex B. New Vaccine Introduction: Action Plan for

PCV-10
This is the 2012 work of a consultant, Teresa Stuart Guida, who developed and initiated a communication strategy for
the
introduction of PCV-10, the vaccine to prevent pneumonia. It may be helpful as the IPV is introduced in mid to late
2015.
Integrated Advocacy, Social Mobilization and Communication Strategic Plan for Routine immunization and
PCV-10 (February – June 2013)
Communication component
Activities Role &
Responsibilities
Resources Time-line
Advocacy Meetings /Briefing with select group of
parliamentarians for prevention of death from vaccine preventable diseases.
EPI Cell UNICEF WHO
Technical support provided to organize meetings/ workshops by unicef
March-April
Fortnightly updates/releases on vaccine preventable diseases to raise threat perception through media
GoP-EPI-Cell UNICEF WHO
March-June
- True stories on vaccine preventable diseases - Short documentaries on each disease including pneumococcal
GoP-EPI Cell UNICEF WHO
EPI-Cell GoP Technical support provided by UNICEF
March-June

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Forewo

Pakistan at a Glance and the 18th

Background on the Expanded Program on Immunization (EPI) and t

The Expanded Program on Immunization

The Polio Eradication Initiative and Its Relationship

The Evidence: Findings from 2014 Knowledge, Attitudes, Practices

The Pakistan National Communication Strategy for Routine Immuni

Eight Core Elements of the

Resource Requirements and

Annex C. Key Characteristics of Communication Channels in 92131

Annex E. Matrices for Costed Implementation 47475

List of Tables, Boxes

Table 1. Childhood Vaccination Schedule in

Table 2. Attitude towards Immunization and (Self-reported) Practice of Immunization by Socio-Economic

Table 3. Caregiver Awareness by (a) Disease and (b)

Table 4. LHW Awareness by (a) Disease and (b)

Table 5. Methods of Disease Prevention –

Table 7. Comparison of Immunization Status with Primary Communication

Table 8. Time Spent on Commute and Wait and Money Spent on

Table 9. Lack of Vaccines (Reasons given by Caregivers to

Table 10. Reasons for skiping vaccines

Box 1. Pakistan’s EPI Targets for End of 2018 and Outcome

Box 3. Seven Barriers to Full Immunization of

Box 4. Participant Analysis: Key to Successful

Box 5. Risk Communication Planning and

Box 6. Barriers that can be Addressed through the

Figure 1. Province/Area Map of Islamic Republic of

Figure 2. Polio Cases in Pakistan, 2012-2014

Figure 3. Source of Awareness of Routine Immunization -

Figure 4. An Eight-pronged Communication Strategy

Providing Immunization Services to every eligible child of Pakistan is a commitment of

In the vision of the Prime Minister, Government of Pakistan, Muhammed Nawaz

Immunization programme aims at protecting the children against vaccine-preventable

The technical assistance provided by the UNICEF in this regard is highly

The Routine immunization communication strategy also creates opportunities to

An effective Communication Strategy for Routine Immunization involves planned

I also appreciate technical assistance of the UNICEF in preparing of this

An important component of the Government of Pakistan’s Health Strategy is an

The effective flow of Information about the disease burden, cost-effectiveness of

UNICEF in Pakistan works to provide safe, efficient and cost-effective vaccinations to

Pakistan’s Expanded Program on Immunization (EPI)

Many people believe that when someone knows about or

In the case of the national KAPB (including “Behaviours”)

This strategy presents an overview of one small but

This document makes some overall suggestions for

Jammu & Kashmir

Pakistan from a semi-Presidential to a Parliamentary

Immunization is one of the most effective public health

Regulations and Coordination, Communications Comprehensive

THE EXPANDED PROGRAM ON

• Pertussis (whooping cough)

• Hepatitis-B (introduced in 2003)

• Hib Meningitis (introduced in 2009)

• Pneumonia (introduced in 2012)

Despite almost 35 years of the EPI’s existence, in 2013, the

Table 1 shows the vaccination schedule as of January 2015.

BOX 3 - SEVEN BARRIERS TO FULL IMMUNIZATION OF CHILDREN

KAPB FINDINGS BY BARRIER ​ [[

Hepatitis B 37 26 94 92 Pentavalent* 85 88 Chicken Pox 56 56 Typhoid 50 51

TABLE 4 - LHW AWARENESS BY (A) DISEASE AND

(a) By Disease (b) By Vaccine Urban Rural Vaccine Urban Rural

*Pentavalent: Haemophilus Influenza type B, Diphtheria, Pertussis, Tetanus,

CONCERNS OF CAREGIVERS ABOUT SAFETY OF

TABLE 6 - LHW BELIEFS ABOUT PEOPLES’ USE OF VACCINATION AND OF

KAPB FINDINGS BY BARRIER [[

Suggestion: One step that can be taken immediately is

Suggestion: In 2015, all immunization (routine and polio)

Figure 2 - Behaviour and Change Outcomes by SEM Level30

Cross--cutting Social Change Outcomes: Inclusion