title: The Role of Risk Communication for Improving the Immunization Coverage of Children in the Transitory Population in Hangzhou, China
Creators: name: Zhu, Bing
Publisher: name: Griffith University
Year: 2019
Subjects: subject: Immunization
subject: China
subject: Risk communication
subject: Broader regional application
subject: Communicable diseases

description: Immunization has been one of the greatest public health successes, with the ability to prevent morbidity and mortality due to infectious diseases, particularly among children. Its success relies on high levels of coverage. However, globally immunization coverage is uneven and very low in certain populati ons resulting in high rates of avoidable disease burden and death. Evidence demonstrates that the population most at risk of low immunization coverage is the children of internal migrant laborers, moving from place to place to seek temporary or short term work. This is the case in China. In China, since a market economy was adopted four decades ago, a large number of people have been drawn from rural to urban areas to meet the increasing need for labor. Under China’s special housing registration system (t he Hukou system), people are registered to a particular area for housing and other social welfare entitlements. Rural migrants cannot obtain urban household registration status, nor are they entitled to the same social welfare and health services as urban residents. Moving from city to city in search of work, these transitory laborers are often called ‘the floating population’ due to the transitory nature of their work and residency. There is mounting evidence that children of this transitory population are more likely to miss immunizations and thus face greater threats from infectious diseases. Literature also points to the urgent need for effective strategies to improve immunization coverage for these transitory populations, not only to protect migrant chi ldren, but the community at large. However, little is known about how to address this problem. Studies have examined the complexities of the organizational, cultural, socio economic and personal factors influencing the transitory population’s participatio n in the immunization program. They reveal three key reasons why migrant children miss their immunizations: 1) the ir parents lack information regarding the benefits of immunization; 2) a lack of coordination and collaboration among relevant stakeholders in the immunization delivery system to reach out to and communicate with this population; and 3) the current immunization strategy only emphasizes health education without considering other factors, nor assessing the needs of relevant stakeholders such as de cision makers and program managers, Center for Disease Control staff, health practitioners, community leaders, the media, and most importantly the parents. This places a burden and an additional workload on local health workers to reach the transitory po pulation and provide better services. As evidence demonstrates, these practices have not succeeded in strengthening multi stakeholder collaboration to improve immunization coverage, nor in reaching the transitory migrant population who have missed immuniza tions. Thus, a well designed risk communication strategy may be crucial for the effective implementation of an immunization program for the children of the transitory population. Risk communication has been gaining increasing recognition in recent decades as a useful tool for conveying information about risk among stakeholders. It aims to build trust, enhance information flows and mutual understandings among stakeholders, and to build the public’s confidence in and adherence to public health policies. Apar t from communication about risk and uncertainty, risk communication also facilitates decision making, conflict resolution, two way communication, public participation, and multi sector al collaboration. Yet in China, risk communication’s role in improving i mmunization coverage among the transitory migrant labor population has not been thoroughly investigated. Consequently, strategies have not been developed to improve communication between key stakeholders to help overcome barriers to multi sector collaborat ion. To fill this gap, this research aims to examine the role of risk communication in improving immunization coverage for the children of the transitory population applying a stakeholder analysis and a comprehensive community needs assessment in Hangzhou City. It investigates how key stakeholders in selected settings perceive risk in immunization practice, and the various determinants impacting on their decision making over whether to accept immunization, on dealing with adverse events following immunization, a nd other conflicting interests between experts, organizations, communities and individuals. Stakeholders for the National Immunization Program delivery system are analyzed, then the community needs and the status of communication and collaboration between different stakeholders is assessed. Consequently, a risk communication strategy for improving the immunization coverage of children of the transitory population is developed. This study applies mainly qualitative methods supplemented by quantitative secon dary data available on immunization coverage and demographic characteristics. It collects qualitative data to assess stakeholders’ needs and to redefine the role of risk communication through a literature review, interviews and focus groups. In addition, i t conducts two case studies in two families, one with good resources, and another with limited resources which is more isolated. Participants of the study represent key stakeholders of Hangzhou’s immunization program delivery system and the transitory po pulation. The fifty seven interviewees and ten focus group participants come from multiple sectors and interest groups including ten immunization program coordinators and staff from national and provincial level Ministries of Health, and the Center for Dis ease Control and Prevention; twelve parents, twelve health workers, twelve local residents, and eleven community members. Key findings of t his study are:  T he comprehensive community needs assessment of the transitory population reveals that, due to their social circumstances and inequitable access to social and health services the transitory population in contemporary China is faced with many health challenges. Of particular concern is their children’s low immunization coverage. T his has also increased the threats of communicable diseases to their health T he community needs assessment also reveals that the various stakeholders’ concerns and needs, particularly those of the transitory migrant population and local health workers, ha ve not been fully considered and fulfilled.  T he stakeholder analysis describ es the delivery system of the National Immunization Program for children of the transitory population in Hangzhou This delivery system for the transitory population contai ns many sectors and departments Each of them has different functions and activities in the system . To effectively improve the Program’s performance, these departments need a better understanding of the system in which they operate, and sufficient cooperation betw een them must be fostered. I t would be necessary and helpful to integrated multi stakeholders efforts to improve the work of the immunization service  This study indicates that risk communication is crucial for the success of public health intervention pr ograms such as the immunization program. To facilitate the risk communication, information sharing and development of cooperation mechanism s are necessary. This study collected t he contents and channels of information exchange between stakeholders. M ore important ly , the decision making factors for each stakeholder concerning immunization for children of the transitory population have been collected and analyzed  Finding s of this study reveal that current communication between different stakeholders is not good. This is caused by ineffective communication methods, the simplistic contents of the communications, an imbalance of information among different groups, inefficient communication channels, and most importantly, the transitory population’s lack of tru st in the official information. Based on the researcher’s experience and the study findings, this study recommends that:  A comprehensive community needs assessment should be conducted to identify the needs of both children from the transitory population a nd the grassroots health workers to inform the development of intervention programs tailored to them.  The traditional health education approach to promote immunization to the transitory population has limitations. To facilitate program implementation, ris ks concerning the delivery of the National Immunization Program should be fully communicated to the different groups of stakeholders in accordance with the risk communication framework.  A community empowerment framework should be applied to design strateg ies and to enable the target population to gain access to what they need through four means: resources, networks, information, and decision making. These include redistributing educational resources through the effective channels identified by the migrant population itself, recruiting community volunteers to reach and inform the migrant population on immunization , and reorienting the health service following suggestions from the migrant population and local health workers.  Risk communication can help facili tate multi sectoral collaboration and empower vulnerable populations to participate in public health programs. Thus, it should be applied to broader areas of public health.  The government service providers need comprehensive community needs assessments, c ommunity empowerment, and effective partnerships and capacity building to address the transitory population’s public health issues.  Health workers from the grassroots level should be more involved in the design and assessment of public health intervention programs to achieve and sustain success. The results of this study should be applied to improve the immunization services for the transitory population and to form the basis for developing a risk communication strategy with a broader regional application. This study contributes to international health security in general, and to China in particular due to its substantial transitory population, whose children are at high risk of suffering from communicable diseases. It will increase our understanding of the ories, concepts and factors relating to decision making processes and risk communication strategies, which is an important knowledge gap in current public health emergency management, disease outbreak response, and population based program design, coordination and delivery.