The Hamlets That Stayed Away
Village Godhna has 1,840 people in two hamlets, Upper and Lower, divided along caste lines and by a long-running panchayat election rivalry. The last Village Health, Sanitation and Nutrition Day covered 38 of 96 eligible children for routine immunisation. Four children had fever the following week, and one had a brief febrile convulsion two days after measles-rubella vaccination. By the time you visit, the story circulating in Lower hamlet is that 'the injection causes fits'. The ANM says she will not enter Lower hamlet without police; the ASHA is from an Upper hamlet family and is distrusted there; the local registered medical practitioner, who treated the febrile child, is telling mothers to 'skip the government vaccine'. The Anganwadi Worker is willing but has no influence in Lower hamlet. The next VHSND is in nine days and the block wants coverage above 80%.
1. Map the stakeholders and identify the entry point you would use in Lower hamlet, with reasoning.
Read the worked answer
Stakeholders: the ANM, who controls the session but is refusing one hamlet; the ASHA, whose affiliation makes her a liability in Lower hamlet; the registered medical practitioner, an opponent with clinical credibility because he treated the child; the two hamlet-level political groups; and the mothers of under-two children, who are the actual target rather than the whole village. Entry point: not the ANM, not the ASHA, and not a public meeting, which would be read as taking a side in the faction fight. Begin with a home visit, with the Anganwadi Worker, to the family of the child who had the convulsion. Listen first, take the mother's account seriously, and ask her what would make her comfortable. She is the most credible voice in Lower hamlet and the only person whose reassurance dissolves the rumour, because she is its evidence. In parallel, meet the practitioner privately as a professional, since he can confirm the fever preceded the convulsion. Convene the session through Lower-hamlet mothers, never through the ASHA.
2. How would you respond to the convulsion rumour and to the practitioner, without dismissing the family's experience?
Read the worked answer
A convulsion with high fever in a young child is common and usually not caused by the vaccine, but opening with 'it is a coincidence' is exactly what makes families stop listening. Sequence matters. Acknowledge first: 'your child had a fit, that is frightening, and you are right to ask about it.' Then separate the events in time - ask what the child's temperature was that day, whether she was unwell beforehand, and what the doctor treated her for. Explain that fits with high fever occur in small children with or without vaccination, and that the reason to go to the PHC now is follow-up for the child, not defence of the vaccine. Give the family a named person to return to if fever recurs. For the hamlet, let the mother and the practitioner carry the message rather than issuing a defensive announcement. Do not attack the practitioner publicly; ask him privately what he advises for a child with fever. File the adverse event through the AEFI channel - that is what protects the programme's credibility over the next year.
3. Give a nine-day plan with two measurable indicators.
Read the worked answer
Days 1–2: home visit to the convulsion family with the Anganwadi Worker; private meeting with the practitioner. Days 3–4: house-to-house listing in Lower hamlet with two local mothers, identifying every child due a dose and every pregnant woman; do not use the ASHA for this list. Day 5: a small mothers' meeting in Lower hamlet, twelve to fifteen women, chaired by a Lower-hamlet woman, with the ANM present but not leading. Days 6–7: reminder visits and MCP card checks. Before day 7, fix the session site at the edge of Lower hamlet rather than at the Upper-hamlet anganwadi, and get the ANM's attendance confirmed in writing; if she still refuses, escalate the same day to the Medical Officer and the CDPO. Day 9: the session, with the Anganwadi Worker and a Lower-hamlet volunteer managing the queue. Indicators: the number of Lower-hamlet eligible children immunised on the day against the number listed, and the proportion of Lower-hamlet eligible children whose cards were checked before the day. A third worth watching: no family refusing after counselling.