Chapter 4: Create demand for immunization services

Creating demand for immunization services is a critical component of maternal, newborn, and child health care in Kenya. Community health professionals play a vital role in ensuring that children under five years receive timely immunizations to prevent vaccine-preventable diseases. Mapping children under five according to established standards allows targeted interventions, efficient resource allocation, and improved immunization coverage. This chapter focuses on the roles of various community stakeholders involved in mapping and mobilizing demand for immunization services.

4.1 Children under five years mapped according to standards

Mapping children under five years is an essential community health strategy. It means identifying, locating and documenting every child under five years of age in a community health unit so that each one can be reached with immunization services. The process needs collaboration among community health promoters, community health assistants, community leaders, health workers and civil society groups, who together create accurate lists and maps that reflect the immunization needs of the population. In Kenya's diverse communities, mapping supports tailored outreach, especially in rural areas and informal urban settlements where access to a health facility may be limited. This topic deals with the mapping itself. Linking the mapped children to a health facility and the immunization schedule are covered in the topics that follow.

What mapping of children under five years means

A child under five years is any child from birth up to the day before the fifth birthday. Mapping has two parts that work together: a register that lists every such child with the details needed for follow-up, and a map that shows where the children live. The register answers the question of who the children are and which vaccines each one has received. The map answers the question of where they are, which villages and homesteads need the most attention and which are far from the facility.

Example: a community health unit may cover a market centre, a river crossing and scattered homesteads. A hand-drawn map made with the community marks the facility, the roads and footpaths, the water points and each household, and uses a symbol for households with children under five years and a different symbol for households where a child has missed a vaccine.

Why children under five years are mapped

• Reaching every child: A child who is not known to the health system cannot be reminded, traced or vaccinated. Mapping finds children who have never been seen at a facility.
• Finding children who have missed doses: Comparing the register with each child's immunization record shows which children are overdue.
• Planning outreach: The map shows clusters of unreached households and the distance to the facility, so outreach sessions are placed where they are most needed.
• Estimating the target population: The number of children under five years in the unit is the base for measuring coverage and for planning vaccine and supply needs.
• Keeping information current: Births, deaths and movement of families change the list over time, and a mapped community is easier to update than an unmapped one.

Standards for mapping

Mapping is done to common standards, so that every unit produces information of the same quality, which the facility and the health management team can use. In practice these standards come down to the principles below.

• Complete: Every household in the community health unit is visited, including households that are far away, newly arrived or hidden from view.
• Current: The register is updated at regular intervals and whenever a birth, a death or a move is reported.
• Accurate: The child's age and date of birth are taken from the Mother and Child Health Booklet or the birth notification where one exists, and are not guessed when a record is available.
• Standard tools and definitions: The unit uses the official household register and the unit boundary agreed with the facility, and a child is counted once only.
• Confidential: Personal details are shared only with those who need them for care, and registers are kept safely.
• Linked: The list is shared with the health facility that serves the unit, so that both sides work from the same information.

Information recorded for each child

• Identification: The child's name, sex and date of birth.
• Caregiver and contact: The name of the mother or caregiver and a telephone number or the name of a neighbour who can be reached.
• Location: The village, the household and a landmark that makes the home easy to find.
• Immunization status: The doses received, as shown in the Mother and Child Health Booklet, and the doses that are due.
• Other service contacts: Whether the child attends growth monitoring and whether the birth has been notified for registration.

Steps in mapping children under five years

1. Agree on the boundary of the community health unit with the community health assistant and the facility, and meet local leaders to explain the purpose of the exercise.
2. Draw the base map with community members, showing the facility, roads, rivers, markets and the homesteads, and number the villages.
3. Visit every household and ask whether any child under five years lives there, including children staying temporarily with relatives.
4. Record each child in the register and ask to see the Mother and Child Health Booklet. Copy the date of birth and the immunization record exactly as written.
5. Mark the households on the map with symbols for children who are up to date, children who are overdue and children who have never been vaccinated.
6. Verify the list with the facility records and with the assistant chief's office or the village elders, who may know of births, deaths and families that have moved in or out.
7. Present the completed map and register to the community health assistant for review, and display a summary where the community can see it.
8. Update the register and the map at the agreed intervals and after every birth, death or move.

Roles of key actors in mapping

• Community health promoter: Visits the households, completes the register and map and keeps them up to date.
• Community health assistant: Supervises the mapping, checks the records for gaps and errors and shares the findings with the facility.
• Assistant chief and village elders: Help to introduce the exercise to households and give information on births, deaths and families who move. Their offices help to mobilise caregivers for immunization days.
• Clinicians and vaccinating health workers at the facility: Compare the mapped list with the facility's immunization records, trace children who are overdue and plan outreach sessions based on the map.
• Civil society and community groups: Women's groups, youth groups and other community organisations help to reach households that are hard to find and to encourage caregivers to attend.
• When a child dies: The CHP of the village records the death, removes the child from the active list and informs the facility, so that other children in the household are visited and any missed vaccines are completed.

Using the map for immunization demand creation

• Prioritise households: Visits are planned first to households with children who have never been vaccinated and then to those with overdue doses.
• Plan outreach: Outreach sessions are held at points close to clusters of unreached households.
• Send reminders: Caregivers are reminded of the date of the next dose through home visits, telephone calls or messages.
• Monitor change: Each update shows how many children have moved from overdue to up to date and where the gaps remain.

Challenges in mapping and how to address them

• Population movement: Families who move for work or seasonal reasons are missed. The CHP asks neighbours and leaders about newcomers and updates the list often.
• Hesitant households: Some caregivers fear vaccines or visitors. The CHP builds trust, listens to concerns, and involves respected local leaders.
• Children without records: Where there is no booklet, the CHP records what the caregiver reports and asks the facility to confirm or issue a booklet.
• Hard-to-reach areas: Long distances and poor roads slow visits. Grouping households into routes and using local guides saves time.
• Errors and duplicates: The same child may appear twice or a child's age may be recorded wrongly. Verification against facility records and supervision by the community health assistant correct these.

Chapter Summary

This chapter focused on creating demand for immunization services by emphasizing the importance of mapping children under five years according to established standards and ensuring they are linked to health facilities based on clear criteria. It detailed the identification of child immunization schedules in line with the Kenya Expanded Programme on Immunization (KEPI) and outlined the classification and referral process for adverse effects following immunization, distinguishing between mild, moderate, and severe reactions as per Ministry of Health guidelines. The chapter highlighted the necessity of follow-up for children after health facility visits and the role of health education in promoting immunization uptake. Nutritional assessment and supplementation were covered extensively, including growth monitoring, developmental milestones, vitamin A supplementation, and deworming protocols. Growth monitoring parameters such as weight, height, head circumference, and body mass index were discussed as critical indicators of child health. Finally, the assessment of child developmental milestones was presented for various age groups, underscoring the collaborative involvement of community health assistants, clinicians, and civil society members in supporting child health and addressing related health issues like infections, anemia, childbirth complications, and comorbidities.