Behaviour change communication (BCC) is a process of any intervention with individuals, communities, and/or societies to develop communication strategies to promote positive health-related behaviours which are appropriate to their settings.By improving health worker communication with caretakers and communities and focusing on messages that address mothers concerns about immunisation, it can help reduce the number of "left-outs" (unreached) and drop-outs by raising community support and demand for services.

Desired Immunization-Related Behaviours

Immunisation services are less likely to be used by people who are uninformed, dissatisfied, too busy, poor and powerless, misinformed and distant. Achievement of immunisation goals is affected by the behaviour of many groups, including community and religious leaders, health care providers, managers and supervisors, caretakers and their families.

Some of the desired behaviours for different groups that affect immunisation services are:

i) Mothers and other primary caretakers:

• Bring children to immunisation service delivery points at the ages recommended in the national schedule.
• Bring each child's health or vaccination card to each health visit.
• Seek tetanus toxoid immunisations for yourself and bring your health card. (This applies to mothers and other women of childbearing age.)
• Fathers:
• Bring children to immunisation service delivery points yourself, or encourage their mother to do so.
• Provide mothers with money for transport or other expenses related to immunising children.

ii) Health Workers:

• Perform immunisation tasks correctly, including those that ensure safe injections.
• Give mothers and other caretakers essential information and treat them respectfully.
• Work with communities to schedule and organise services to make them convenient for parents.
• Praise families whose children are fully immunised by one year of age.

iii) Community Leaders:

• Describe the benefits and safety of vaccinations to others in the community.
• Remind families when children need to receive the next dose(s) of the vaccine.
• Encourage families to complete each child's basic immunisations in his or her first year of life.
• Inform families about outreach services, supplemental immunisation activities, and new vaccines and improvements in the immunisation program.
• Assist health facility staff in planning and monitoring services.
• Provide logistical support, e.g., by transporting vaccines, supplies, and staff.

iv) Political and public health leaders:

• Allocate sufficient financial and human resources for immunisation services.
• Show personal support for immunisation services.

The role of BCC:

• Achieve higher coverage rates for all antigens and reductions in missed opportunities, unreached children, and drop-out rates by mobilising communities to support and plan immunisation services;
• Improve quality of services to meet demand, improve interaction between health workers and communities, and improve safety of injections and safe handling of vaccines; and
• Prevent or dispel misinformation and doubts related to immunisation through the use of multiple channels, information sources, and media that influence the population and public opinion.

How Does Behaviour Change?

The stage of behaviour change in relation to information goes through:

• Pre-Awareness: People in this stage have no intention to change behaviour in the foreseeable future. They are unaware of the risk or deny the consequences of risky behaviour. They just don't know.
• Awareness: People are aware that a problem exists, are seriously thinking about overcoming it, but have not yet made a commitment to take action.
• Contemplation/Intention: People intend to take an action shortly and may have taken some inconsistent action in the recent past.
• Trial/Practice: People modify their behaviour, experiences or environment to overcome their problems; the behaviour change is relatively new.
• Adoption: Individuals work to maintain the behaviour change over a long period.
• Maintenance/Telling others: Wouldn't think of doing it any other way. People talk about their experience and advocate for others to try it, too.

Strategies of Behaviour Change Communication

i) Advocacy is a political process by an individual or group which aims to influence public-policy and resource allocation decisions within political, economic, and social systems and institutions. In the context of EPI activities, this could refer to an activity which aims to gain the support of stakeholders, community leaders and local politicians, and to encourage community acceptance of and commitment to the EPI. There are many activities and strategies which can be used in advocacy like lobbying, meetings, negotiation, project visits and use of information and education resource.

ii) Community mobilisation is a process through which action is stimulated by a community itself, or by others, that is planned, carried out, and evaluated by a community's individuals, groups, and organizations on a participatory and sustained basis to improve the health, hygiene and education levels so as to enhance the overall standard of living in the community. The advantage of community mobilisation is it can motivate the people in the community, build their capacity, mobilise and release local resources, promote long-term commitment to sustain behavioural change, develop the feeling of ownership, etc.

iii) Community conversation is a process of discussion of a particular issue, for example, the causes of high dropout rate in the immunisation program, and can lead to a way of finding solutions to particular problems. When you conduct community conversation, you need to consider the purpose of the interview, who should attend or be invited, preparing the agenda for the meeting, deciding on the date, time and place of conversation, and facilitating the conversation in non-judgmental approach.

iv) Interpersonal communication is a person to person, a two-way, verbal and non-verbal interaction that includes the sharing of information and feelings between individuals or in small groups that establish trusting relationships. Interpersonal communication is essential for persuading and convincing individuals and target audiences about the value of the proposed behavior change, addressing rumors about adverse effects of immunization, helping to mobilize resources from the community, explaining to caregivers about the immunisation status of the child and telling the caregivers about the next immunisation(s) that the child will need.