Tikakaran Chakra: A Tool to Increase Awareness on Timely Vaccination

Covering more than 308,252 square kilometers, Madhya Pradesh is the second largest state in India and has the fifth highest population in the country.

A 2019-2020 National Family Health Survey showed a significant increase, 23% in four years, in Full Immunization Coverage at 77%. This could be attributed to intensive national level campaigns including Mission Indradhanus (MI) and Intensive Mission Indradhanush (IMI), programs that aim to reach the most remote populations, cold chain augmentation and supply chain optimization, which led to increased access to vaccines at the last mile and improvement in data quality using tools such as eVIN, HMIS and RCH. However, gaps still remain when it comes to achieving 90% Full Immunization Coverage.

The Challenge of Low Coverage

Over the last two decades, several surveys have tried to unpack the drivers of low immunization coverage in Madhya Pradesh, some of which include the following:

• 40% of the children who remain unvaccinated or partially vaccinated, are due to the caregiver awareness gap while a further 24% are unvaccinated due to family reluctance
• Data shows that immunization coverage correlates strongly with mothers’ schooling, but with many caregivers uneducated and unaware, a heavy reliance on village mobilizers and health care workers for reminders about sessions continues. However, data shows that the mobilizers and healthcare workers still face challenges in effective messaging.
• More than 70% of Madhya Pradesh’s population is rural and around 21% population is tribal [2]. Additionally, 25% of Madhya Pradesh’s area is forest, resulting in accessibility issues on account of challenging terrain.

The Government of Madhya Pradesh (GoMP), in partnership with Clinton Health Access Initiative (CHAI), devised an innovation for improving the communication capacity of the frontline workers that in turn would also enhance demand for routine immunization.  Already, CHAI had supported the GoMP’s State Routine Immunization Division to achieve its coverage and equity goals by strengthening program review mechanisms, data systems, cold chain and enhancing demand.

Nitin Kothari, a senior manager at CHAI, who leads the design, planning and implementation of the Immunization Program and Supply Chain strategy in Madhya Pradesh, shares, “The state needed to increase communication capacity and provide easy-to-use interpersonal communication tools to frontline workers to enable them to deliver correct and complete messages to caregivers.”

Building a New Tool

According to the Indian health system, every village is supposed to have social mobilizers at the village level, who are known as Accredited Social Health Activists or ASHAs. ASHAs are the link between the government and communities as they pass on health information at household level. Meanwhile, Auxiliary Nurse Midwives (ANMs), are the first medical point for village populations, and they provide primary health services to the community including vaccination.

For those with vaccine-eligible children, the ASHAs follow up with caregivers and encourage those caregivers to get their children vaccinated. They also prepare “due lists”, which include names of vaccine-eligible children and the vaccines they are due for. ANMs provide vaccination services along with key immunization messages to caregivers.

“We devised an immunization wheel to bridge the awareness gap. The design focused on helping vaccinators present the information to caregivers in a simplified manner,” shared Nitin.

The development of the wheel began in April 2020. The first design was created with ANMs in mind: “Because the vaccinator is the key point person when a child is immunized, we believed giving ANMs an interpersonal tool would be the first step to improving the communication process. By using a visual item that clearly communicated due dates, caregivers would be clear on when their children were due for the next dose,” said Nitin.

The first iteration of the tool was shared with government and district immunization officers as well as the community. Reviews from all three stakeholders revealed that the needs of the caregivers were unmet, necessitating a redesign.

“The immunization officers at district and block level and the frontline health workers shared their feedback on the color, design and content of the wheel, so we incorporated these changes,” shared the CHAI team.

The second version of the wheel was developed for ASHAs, who are responsible for giving key messages to the caregivers and mobilizing them to the session sites. The tool was tested with ASHAs who suggested that as mobilizers, it was important that they made their visits with their own immunization wheels to explain to caregivers the importance of vaccination.

Now known as Tikakaran Chakra, the wheel is a cost-effective calendar-like tracking tool designed for ANMs and ASHAs. It has a green indicator at the front and on its edges, with dates listed from January to December. If the green indicator is placed on a child’s date of birth, the subsequent green arrow indicates vaccination dates for up to one year. The wheel also includes the vaccines’ names, the number of doses required and whether the vaccines are oral or injectable. At the center of the wheel, vaccines and booster doses that are to be administered after one year are listed. Adjacent to this is a list are vaccine names and the diseases they prevent.

The difference between the two wheels lies in the color of the wheel as the vaccinator’s wheel is green, while the ASHA’s wheel is pink. The backside of the wheel has unique information for ASHAs and ANMs based on their responsibilities.

As a supplement to these wheels, a caregiver version was developed and tested. The first test cohort was new mothers who were still in the maternity ward, and caregivers whose children were between 1 and 9 months. The latter were given the wheel by the ASHAs as they undertook community visits. This version included strings to allow caregivers to hang them on their walls, decreasing chances of tear or loss.

Promising Results

CHAI recently conducted an impact evaluation study of all three versions of the wheel through a six-month study. “What we have noted is that 70% of the beneficiaries who received the wheels have been able to retain them. Significantly, mothers are now able to recall their children’s due dates. They are aware of immunization and its importance, and don’t have to wholly rely on ASHAs for follow-up,” shared Mehak Bhatia, another member from CHAI who led the study.

From its design to its present use, the Tikakaran Chakra has proven to be a significant, easy and useful tool in driving timely vaccination and, more importantly, emphasizing the importance of complete immunization. The study results show that 92% of the ANMs and 58% of the ASHAs were using the wheel to give immunization related information to caregivers.

Dr. Santosh Shukla, State Immunization Officer, Government of Madhya Pradesh observed that, “The wheel takes into consideration the factors of knowledge, norms and language in the state, and is designed appropriately for the three tiers of actors, which will make it a valuable instrument for long-term success.” With this simple-to-use and timely innovation, Madhya Pradesh is on its way to reaching its immunization coverage targets.

[1] Comprehensive UIP Review, 2018
[2] Census 2011