Our Story with Expanded Programme on Immunization (EPI)

Time and Space Media excels in providing not only creative marketing strategies to create brand awareness and better marketing position for businesses but also has a history of creating winning media strategies for projects of immense global significance related to health and public wellbeing. The company has years of experience in working along with the education, technology, health sector, national and provincial governments, and humanitarian and development organizations like UNICEF, WHO and Bill and Melinda Gates Foundation. At Time and Space Media we play our role in the sustainable development of the world by providing media and communication services to development and health programs.

At Time and Space Media, we envision a world free from diseases and a low morbidity and mortality rate due to diseases. For this we have coordinated with various humanitarian organizations, working for the provision of better health services, to generate awareness about the prevention and control of diseases.

More than 3 million people die of Vaccine-Preventable diseases each year globally.  Approximately 1.5 million of these deaths are in children less than 5 years old. Pakistan is third among countries with the most unvaccinated and under-vaccinated children. In 1974, WHO launched the Expanded Program on Immunization (EPI), in Pakistan, to protect children by immunizing them against 10 deadly Vaccines Preventable Diseases (VPDs). EPI significantly reduced the child morbidity and mortality rate but the immunization coverage is not high enough to avoid individual deaths and transmission of infectious diseases.

To improve the immunization coverage and materialize the dream of disease-free World, Time and Space Media has operated in coordination with UNICEF, WHO, Malinda and Bill gates Foundation and several other philanthropist organizations to disseminate awareness messages to ensure sustainable behaviour change regarding Vaccine-Preventable Diseases in Pakistan.

Problem/ Issue

Vaccine hesitancy is one of the top threats to global health.  Mistaken believes about vaccination process have made more and more children vulnerable to the Vaccine-Preventable Diseases thus compounding the woes to eradicate them. Though these vaccination courses are proven to save lives and are available free of cost, some people are still reluctant to get their kids vaccinated thus putting their children, the families and their community at risk of infectious diseases.

Research indicates that communicating clear benefits of vaccines is not always enough to change people’s behavior about vaccination. Rather people with different cultures and socio-demographic groups need different motivations and tailored communication strategies to address their concerns.

Pakistan has a high burden of newborn mortality and approximately 400,000 children less than five years of age die every year from vaccine-preventable diseases in Pakistan. The Pakistan Demographic Health Survey from 2013 estimated that almost three million children dropped out of the basic course of vaccines every year.  The survey of Pakistan Social and Living Standards Measurement (2014–15) showed that Pakistan’s full immunization coverage was 60%.  In addition, the coverage rate stood at 27–70% with large variations between the provinces, districts, and communities.

In addition to this, the scheduling of immunization doses is critical because if a child is immunized too early or if the immunizations are too closely spaced, it can considerably shorten the period of protection or hamper with the immune response.

Therefore, its crucial to not just address false believes about vaccination but also educate and create awareness about the immunization schedule and inform about the benefits of vaccination courses.

Over the years, Time and Space has coordinated with the public sector and health organizations to create awareness about immunization programs as well as train health professionals in disseminating clear benefits about the vaccination courses.

Our Approach

Pakistan being an underdeveloped country has a dearth of specialists and preventive measures to control viral diseases. Therefore, we adopted an inclusive approach in coordination with UNICEF and GAVI to design the awareness campaign against Vaccine-Preventable Diseases (VPD). The regions with a low ratio of maternal education and empowerment had the highest proportion of unvaccinated and under-vaccinated children. Exhaustive research to understand the psychological and demographic determinants, such as attitudes toward vaccinations and social norms of parents from both rural and urban metros was conducted. Our approach was to educate the families and especially the mothers to change their perception about immunization and inform them about the benefits of immunization to save their kids from 10 deadly vaccine-preventable diseases. Our major goals in coordination with WHO and UNICEF were to

• Change the perception and behaviour of parents about the vaccination process
• Address concerns of parents regarding the benefits of vaccines
• Train health workers
• Increase equitable coverage of immunization services against Vaccine-Preventable Diseases. (VPD)
• Ensure sustainable behaviour change regarding Vaccine-Preventable Diseases.

Time and Space is a veteran in designing awareness campaigns and creating thoughtful strategies for disseminating campaign message, we strive to give our best to ensure sustainable development in all sectors of life. Our services in designing awareness campaigns include

• Designing a campaign plan
• Research and planning
• Determine the needs of the community
• Team Approach
• Develop a campaign message
• Grab individual attention and ignite a strong emotion through your awareness campaign message.
• Reinforce message
• Promoting campaign through multiple media channels

We as communication agency collaborated with various governmental and non-governmental departments and designed the campaign after thorough research about the psychographics and demographics of the targeted audience. Our communication strategy involved both above the line, conventional and mainstream media like TV, radio, Newspaper and Billboards etc. as well as below the line strategies like seminars, workshops, training and celebrity endorsement etc. The message was disseminated using documentaries, rickshaw branding and streamers – helping us to persuasively reach the targeted demographics for ensuring a sustained behaviour change regarding immunization coverage.

Pneumonia

Pakistan has one of the highest infant mortality rates in the world, and over 50 per cent of deaths in post-neonatal children are attributable to pneumonia that can be partially prevented through immunization with vaccines. In 2012, Pakistan introduced the Pneumococcal vaccine to inoculate children less than five years against Pneumonia through EPI.

To make it known to the general public and medical professionals, Time and Space partnered with UNICEF, the UN’s children’s agency to reach out to the districts with the highest ratio of reported pneumonia deaths. We conducted surveys to understand the psychographics, demographics and socio-economic status of residents. It showed that most of the pneumonia associated deaths occur in underprivileged segments of society where mothers are illiterate and dependent on men financially which ultimately gives men the decision making power in houses. Therefore, our goal was to effectively reach out to both parents to decrease morbidity and mortality due to pneumonia. An inclusive approach was adopted to create awareness and behaviour change for the vaccination courses in both parents.

In rural areas, the influential people like headmasters, teachers, Panchayat leaders, Nambardars and Waderas were approached and encouraged to endorse the pneumonia campaign message. Community meetings and gathering were used to maximize awareness about the prevention of pneumonia through vaccination courses.

We arranged communication workshops and training for the health workers to effectively counsel and motivate families for vaccination courses and make sure that all families in their vicinity get their kids vaccinated. They were guided to register all the kids under 5 years of age to ensure immunization coverage for the. Lady health workers were trained for carrying out door to door vaccination. They educated mothers on how to look out for signs of pneumonia in their children to ensure immediate care.

However, the response from the illiterate segment of society was not very encouraging. They are more frightened about the perceived harm from a vaccine than the risk of the disease itself. Therefore Pneumonia awareness documentaries featuring celebrities from diverse backgrounds were aired on national and private TV channels.

TV artists used local languages to emotionally tap the audience. The Scripting, conceptualization and production of Pneumonia awareness documentaries were done after a proper understanding of demographic characteristics, cultural orientations, parent’s perceptions of disease prevalence, their vaccine-related knowledge, and their trust in the information provided by healthcare professionals and government.

Parents from rural, illiterate backgrounds had limited knowledge about the vaccination schedule to protect infants and children by providing immunity early in life. Therefore, 2D animation was used to capture the attention of parents and demonstrate the value of vaccination for the health of children. The animated infographics guided parents with a detailed schedule on the vaccination process

To increase the impact of our campaign, we also used rickshaw branding in both rural and urban metros to make announcements about the vaccination schedules and the arrival of vaccination teams in different areas. The religious leaders were approached for endorsing the campaign message. They made announcements about the schedule of vaccination teams and encouraged parents to get their kids vaccinated against Pneumonia.

In Urban metros, brochures, fliers and streamers were displayed to promote the message of the campaign. In addition to increasing awareness about the importance of immunization, the message also addressed the importance of nutrition and mother health which can play an important role in decreasing the risk of pneumonia in infants.

Measles

At the end of 2012, Pakistan was hit by an outbreak of the measles epidemic.  Many indicate that the outbreak was the result of flooding as the flood areas were dominated by poor, illiterate families. Most of these families lacked adequate resources to get their kids vaccinated. Another factor was their irrational thinking that vaccines are meant to make their children sterile and decrease the growth rate in the country. The outbreak can also be accounted for insufficient routine immunization coverage.

To fight this epidemic, in April 2013, the government launched a campaign to vaccinate every child against measles in coordination with UNICEF. We worked as the communication partners to facilitate the message endorsement. Our first goal was to create awareness about the preventive measures against the viral disease. The team of Time and Space media used an extensive approach to produce and conceptualize documentaries focusing on the prevention and control of the viral disease. We engaged cricketers, TV artists to promote the campaign message. Celebrity endorsement helped in inducing behaviour change about isolating the affected person and using masks in public. The documentary also encouraged avoiding crowded places and repeated washing of hands.

Another documentary promoting the benefits of routine immunization was produced to tap the conscience of parents about the advantages of immunization. Treatment procedure and benefits of early diagnosis were also highlighted to inspire parents to get post-exposure vaccination and immune serum globulin. TV documentaries also aimed to educate people about booster doses.

Since the outbreak of measles affected almost all areas of Pakistan, our approach was to reach maximum people. For this purpose seminars and workshops to address the preventive measures of measles were conducted in all 36 districts of Pakistan. We approached doctors, medical staff, vaccinators and health workers to guide them about diagnosing measles. As many doctors and health workers have never seen measles and the rash can be confused with several other illnesses. They were also trained in educating parents about the preventive measures of measles to avoid exposure to a measles epidemic.

Our strategy included reaching out to the youth and students through seminars, workshops, and lectures as they constitute the majority of the population. Teachers, professors and heads were approached by our teams to endorse the campaign message. In rural areas, community motivators, religious leaders and influential community members aided us in the dissemination of the message. We planned to reach out to the urban metros through an outdoor campaign. For this purpose, streamers, billboards and banners were displayed on roads in all major cities.

In 2018, in coordination with the government of Pakistan, UNICEF and GAVI we launched the nationwide measles campaign to vaccinate all the kids between 6 months and 7 years of age. The campaign urged all parents to vaccinate their children against measles virus during the nationwide anti-measles vaccination campaign. We worked with the government, UNICEF, and GAVI to maximize the immunization coverage from the north-western mountains to the southern coastline. For the first time in history, the far off areas of Cholistan were visited to ensure that no child was left behind.

In addition to this, for past few years, we have worked in close coordination with the public sector to continuously tap the people’s consciousness through awareness campaigns to create a sustainable change in their behaviour about immunization. This may help us to reduce the measles outbreaks in future.

Polio

Pakistan is among the three countries where Poliovirus continues to threaten the health and well-being of children. In 2014, the number of Polio cases in Pakistan prompted the International Health Regulations Emergency Committee to declare the condition a ‘public health emergency of international concern’. Therefore, in 2015, Injectable Polio Vaccine (IPV) was introduced as part of the routine immunization schedule.

The basic literacy rate of Pakistan is almost 60% contributing as a major factor to the vaccine hesitancy. Therefore, an extensive approach was required to tap the consciousness of people from all segments of society. We designed our communication strategy following the goals set by the Global Polio Eradication Initiative (GPEI).

Our first approach was to educate and train doctors and health professionals about the injectable polio vaccine. For this purpose, seminar and lectures were organized in hospitals and medical colleges. Our next step was to guide vaccinators and lady health workers to ensure the dose in a regular immunization course. Lady health workers were trained to use effective communication strategies to convince parents about injectable polio vaccines.

Pakistan has extended family networks faces an issue of consent from family and community elders before the vaccination process. Therefore, our strategy involved reaching out to community elders as well as parents. Seminars and events focusing on the importance and effectiveness of polio vaccines were organized in rural health centres, basic health units, schools and other community centres. The seminars invited local community motivators, political leaders and local artists to address the residents and endorse the polio eradication message.

There is also a widespread misconception about the vaccination courses among some communities that they can harm or sterilize children, or contain monkey- or pig-derived products which are forbidden in Islam. To address this misconception, we approached religious leaders so they can guide parents and the general population.

Parental refusal is a significant hindrance to the vaccination campaign due to misconceptions regarding the purpose or effectiveness of immunization. Documentaries in local languages were produced to reach the maximum people for guiding them about the purpose and effectiveness of polio injection.  The message was disseminated in local languages to increase impact.

DTP Boosters

In 2018 DTP booster containing the pentavalent vaccine was launched by Department of Primary and Secondary Health care. DTP booster is a combination of 5 individuals vaccines, designed to protect against Haemophilus influenza, Tetanus, Hepatitis B, Whooping cough, and Diphtheria. We designed the launching campaign to introduce it as part of regular EPI programme. Previously EPI programme was limited to vaccination schedule for the first two years. While DTP booster was to be injected at 4-5 years of age. Therefore our major target was the parents belonging to both rural and urban metros.

We produced documentaries to educate people about the importance of DTP booster as over time the effect of DTP injection wears out. Therefore, it’s essential to get another dose of DTP to minimize the risks of diphtheria, whooping cough and Tetanus.

The team conducted workshops and lectures in rural health centres, basic health unit, Tehsil headquarters hospital and district health quarter hospitals for the medical professionals. Doctors, vaccinators, and lady health workers were educated and trained about the importance of DTP boosters. They were given guidelines to make people aware of DTP boosters.

Events were organized in local community centres and schools to increase the DTP booster coverage. Teachers and instructors from both public sector and private sector schools were approached to endorse the campaign message.

Meningitis

Acute Bacterial Meningitis (ABM) is a serious public health problem demanding prevention, early diagnosis, effective treatment, and control. Pakistan introduced the Meningitis vaccine as part of the Expanded Programme on Immunization in 2009.

We designed a comprehensive public awareness campaign to improve public understanding of meningitis. The campaign focused on educating parents about the significance of vaccination against meningitis. For this purpose, we reached out to the teachers and community leaders for endorsing the message of vaccination courses. Seminars and lectures were conducted in community centres for raising awareness about the deadly disease.

In coordination with the Primary and Secondary Health care, we produced documentaries focusing to raising disease awareness, underscoring the importance of prevention through vaccination and improving support for those dealing with the potentially devastating consequences of the disease.

Religious leaders, community motivators, and activists were engaged to catch the attention of the population. We included testimonials of parents of affected children. The documentaries also highlighted the health facilities to raise awareness about the rural health centres and Basic Health Units. These health centres facilitate parents to ease the process of vaccination courses for them.

We also engaged medical professionals to increase the parent’s compliance with the vaccination courses. Lady health workers were trained on improving communication skill to effectively reach the parents. The general hindrance in the vaccination courses exists because parents feel reluctant to get their kids vaccinated mainly because of their paradoxical beliefs.

Childhood Tuberculosis (TB)

Childhood tuberculosis is a major public health problem in Pakistan with roughly 20% of tuberculosis patients detected every year being children under the age of 15. The Expanded Programme on immunization includes a TB bacilli Calmette-Guerin (BCG) vaccine that though does not provide 100% protection against TB, but it significantly decreases the chances of your child getting this serious disease.

In coordination with Primary and Secondary Health care, we designed an aggressive communication strategy to educate parents about the vaccination course including the BCG vaccine.

Our approach was to produce documentaries based on the awareness messages delivered by community motivators, activist and health professionals. The documentaries also highlighted the importance of precautionary measures to avoid the spread of disease in children.

The cultural orientation of some areas in Pakistan discourages vaccination courses because of their faulty believes that vaccinations can sterile their children and such courses are prohibited by Islam. To counter these false believes we approached religious leaders to change the orthodox mindset of people.

Workshop and lectures were arranged in coordination with WHO to train the paediatricians and health professionals to communicate the benefits of vaccination courses to parents.  Lectures were conducted in RHCs. BHUs to train the lady health workers and guide them about community counselling.

In the urban metros, we published print ads and brochures to tap the conscience of patients. Steamers were displayed on roads to catch the attention of the public.  Events and workshops were organized in community centres to educate parents. The awareness campaign successfully mobilized parents to get their kids vaccinated.

Rotavirus

Incidence of Diarrhea due to Rota Virus in Pakistan is estimated to be around 24% according to WHO data. This deadly disease can be prevented by administrating a dose of Rotavirus vaccine in the first 12 months of age. These vaccines can prevent almost 91% of sickness related to rotavirus infections. Evidence has proven that the rotavirus vaccine is a highly effective, efficacious and efficient in preventing infective diarrhoea due to Rotavirus.

The government of Pakistan included the Rotavirus in EPI in 2017 to decrease morbidity, diminish mortality, and shrink the number of hospitalizations due to Rotavirus. However, a comprehensive approach was required to make it knows to the public. For this purpose, we coordinated with the Primary and Secondary Health care department to design a media strategy to disseminate the message to all segments of society.

Our first approach was to reach the health professionals and health workers and guide them about administrating the dose of Rotavirus vaccine as part of vaccination courses. We trained lady health workers and vaccinators to effectively reach out to the parents and convince them for the routine vaccination of their kids.

In rural areas, the literacy rate is much lower than the urban metros. Therefore, to reach out to these people, we coordinated with the community motivators and convince them to endorse the immunization message. We visited different areas and organized vaccination camps to ensure most children could get the vaccination course. We also used Rickshaw branding to tap the public about the importance of vaccination.

In Urban metros, streamers, brochures, billboards and banners were displayed as part of the awareness approach. The campaign successfully generated awareness as well as created a call to action for parents.

Hepatitis B

According to the WHO reports, the prevalence rate of Hepatitis B is 2.5% of the population. But the timely vaccine can prevent you from the Hepatitis B virus. The vaccine was introduced in Pakistan Government’s EPI program in 2009. It has replaced the previous DPT and Hepatitis B vaccine. Three doses of this vaccine are given to children in Pakistan in the first year for free, at 6 weeks, 10 weeks and 14 weeks of age.

Effective awareness strategy was required for HepB prevention and control. Information related to knowledge and awareness of community members is crucial to design prevention programs in the community. For this, purpose in coordination with the Government we conceptualized and produced documentaries for creating awareness about the significance of immunization schedule.

Our target audience consisted of two segments, the rural and urban population. For reaching out to the people in urban areas, we used brochures, streamers and conducted workshops in different community centres. However, it was comparatively difficult to reach out to the people in rural areas as these people especially those with low socioeconomic status and illiterate background have superstitious beliefs about diseases. Their orthodox behaviour, lack of education, and fear of manipulation contribute to the increased rigidity against vaccination courses. Therefore, we approached Panchayat leaders, activists, community motivators and teachers to effectively disseminate the message.

The training of health workers and vaccinators was also a major approach as effective communication can induce behaviour change. They were trained to educate and guide mothers against the preventive measures and control of disease through a door to door campaign.

Success/ Effectiveness:

As a communication agency, various communication and awareness campaigns by Time and Space Media have successfully addressed the concerns of parents and educated them about the benefits of vaccination courses. The efforts of time and Space media in coordination with GAVI, USAID, WHO and national and provincial governments are visible as neonatal tetanus was successfully eliminated from Punjab in 2016. In addition to this, the current EPI coverage for fully immunized based on PDHS (2012–2013) and PSLM (2014–2015) surveys are 65% and 88%, respectively.

The new immunization policy predicts Pakistan’s Vision 2025 as to reduce the infant mortality rate from 74 to less than 40 (per 1000 births) and reduce the maternal mortality rate from 276 to less than 140 (per 1000 births). To achieve SDG 3 for Pakistan, Time and Space vow to continue its work with UNICEF and WHO to ensure this. Time n Space Media Ltd vows to use its expertise in strategizing the communication plans and dissemination of information.