Man speaks into loudspeaker during vaccination campaign. Photo: WHO/C. Black
Achieving high levels of coverage of multiple-dose vaccines – such as the cholera vaccine – takes more than good logistics. Promoting turnout for immunization requires the use of evidence-based community mobilization methods. In 1983, I was involved with some of the early mass immunization efforts in Haiti while working for International Child Care, an organization that led the first mass immunization in Haiti years earlier.
As Zone Coordinator, I would ride motorcycle or get around on horseback – and sometimes just hike Haiti’s endless mountains – with our vaccinators to remote locations of the country. We had to rely on the help of TB Agents, local government leaders, and vaccinators with megaphones to announce posts and to mobilize people to come to the posts.
These were not sophisticated methods – it was more yelling at people to try to get them to do something. Rumors spread about vaccines, not everyone was reached with announcements, and even though vaccines were made available, not everyone turned out. Nowadays we realize that it takes a lot more than this to get the high immunization coverage that will save lives. It requires actively involving communities, gaining people’s trust, understanding how people think, and communicating messages through people that they trust – even people that they choose based on that trust.
We need to move forward: Some community mobilization and behavior change approaches are proving themselves to work better than others, especially those where the person doing the mobilizing has a closer relationship and more frequent contact with the people being mobilized. For example, recent research found that immunization coverage for tetanus toxoid (TT2) and measles increased 16 points and 9 points more (respectively) in programs that used the Care Group approach versus those that used other behavior change and community mobilization approaches during the same years and countries .
Why? Care Groups are based on peer-to-peer behavior change, and neighbors can be quite effective in persuading their closest neighbors to adopt a new behavior, to try out something new, and to shut down rumors. In many – if not most – Care Group projects, women in the community directly choose their peer educator rather than that person being chosen by an organization or community leaders. This assures that the person teaching them and promoting behaviors is someone that they know, trust, respect, and like. This is key to behavior change and to effective mobilization.
Differences in health service utilization: care groups vs non-care groups
Peer educators have also proven themselves to be effective in mobilizing parents to seek out care for sick children, well child care, and other health facility services. Evidence from a larger-scale Food for the Hungry Care Group project in Mozambique, for example, found that care seeking and use of clinical services increased much more in districts using Care Groups when compared with adjacent districts that did not use the approach . Cost-effectiveness is another reason that more and more organizations are using peer-to-peer behavior promotion approaches. Studies have found low costs per life saved for Care Group projects [3, 4], and an unpublished analysis that I conducted recently found a cost per behavior adopted of only $4.18. Combining the interpersonal communication used in peer-to-peer behavior promotion with effective mass media can bring about even better results.
Other community mobilization and behavior change approaches, such as Participatory Learning and Action Groups, have also been found to be effective for changing behaviors and improving care seeking. For that reason, they may be an effective avenue for mobilizing people for cholera immunization. In order to take advantage of these groups, Cindy Pfitzenmaier and I, along with other collaborators and with the support of the CORE Group, the TOPS Project, and CORE Group members, recently created the Cholera Disease Preparedness Community Group Module  which has been distributed through UNICEF and WHO for the recent Cholera outbreak in Yemen, and sent to over 16 countries through USAID’s Office of Food for Peace and The TOPS Program.
It’s time for everyone to put down the megaphone, stop yelling, and start using the quiet power of persuasive neighbors and peer-to-peer communication to boost community turnout for cholera immunization.
 See George et al. BMC Public Health (2015) 15:835 DOI 10.1186/s12889-015-2187, https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2187-2.
 Davis, T., Wetzel, C., Hernandez Avilan, E., de Mendoza Lopes, C., Chase, R.P., Winch, P.J., and Perry, H.B. (2013). Reducing Child Global Undernutrition at Scale in Sofala Province, Mozambique, Using Care Group Volunteers to Contact Mothers Frequently with Health Messages. Global Health Science and Practice 1(1): 35-51. http://www.ghspjournal.org/content/1/1/35.full.pdf
 See Perry et al (2015a), http://www.ghspjournal.org/content/3/3/358 for details on the Care Group approach, and Perry et al (2015b), http://www.ghspjournal.org/content/3/3/370 for results of the approach. The Care Group training manual and other CG resources are available at www.CareGroupInfo.org.
 Tripathy et al. (2010). Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010; 375: 1182-92.
 Pfitzenmaier, C; Davis, T; Srinivasan, A; and McDaniel, S (2016). CORE Group Cholera Module. Washington, DC. Food for the Hungry (FH). http://www.coregroup.org/resources/616-cholera-module