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PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES MODULE 22 Disclaimer: The resource modules were authored by the individuals under the guidance of the UNICEF Regional Office for Europe and Central Asia. The text is presented in draft format and it is expected that it will be adapted and contextualized for use by interested countries. The material has not been edited to official publication standards. UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. Coordination and Editing: Aleksandra Jovic, UNICEF, Early Childhood Development Specialist Lead Author: Bettina Schwethelm, Young Child Health and Development Specialist, Director, MCH-ECD Co-authors: Svetlana Stefanet, UNICEF, Immunization Specialist Sergiu Tomsa, UNICEF, Communication for Development Specialist Contributors: Silvia Sanchez R., UNICEF, Knowledge Management Consultant Viviane Bianco, UNICEF, Communication for Development Consultant UNICEF/ Krepkih Andrey TABLE OF CONTENTS Key Messages Why is this Topic Important to you? ..................................................................................6 Learning Outcomes ....................................................................................................................................6 Pre-Test for this Module ...............................................................................................................................7 Glossary and Definitions ............................................................................................................................10 I. Introduction ..................................................................................................................................111. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing ................................112. Vaccination Trends Globally and in Europe ...........................................................................................................143. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary ..........................................................................................................................15 II. Immunization and Vaccine Preventable Diseases A Major Public Health Achievement ...................161. Childhood Immunization .......................................................................................................................................162. How Vaccines Work .............................................................................................................................................173. The Benefits of Vaccination to the Individual Child and Society ...........................................................................204. Vaccine Safety and Side Effects ...........................................................................................................................225. Family-Held Vaccination Records ..........................................................................................................................23 III. Understanding Barriers to Vaccination ...............................................................................................241. Caregivers Along the Continuum of Vaccine Acceptance, Hesitancy, and Rejection ...........................................242. Understanding how Individuals Make Behavioural Choices .................................................................................26 a. The Behaviour Change Journey ........................................................................................................................26b. Factors Influencing Caregiver Decisions ...........................................................................................................27c. Perception Biases, Beliefs, and Myths About Vaccines The Internet and Social Media ................................31d. The Role of Health Workers ..............................................................................................................................34 IV. Communication Skills and Tools to Support Vaccine Acceptance by Caregiver .................................371. Active Listening Skills ...........................................................................................................................................37 a. Verbal Communication ......................................................................................................................................37b. Non-Verbal Communication ..............................................................................................................................38c. Empathy ............................................................................................................................................................39 2. Working with Caregivers Along the Continuum of Vaccine Hesitancy .................................................................39a. Vaccine-Accepting Families ...............................................................................................................................40b. Vaccine-Hesitant Caregivers .............................................................................................................................41c. Vaccine Refusers and Anti-Vaccine Advocates .................................................................................................44 3. Helping Caregivers Overcome Barriers to Vaccination .........................................................................................46a. Preparing Caregivers for Vaccination and Helping Them Manage Mild Side-Effects ........................................46b. Helping Caregivers Problem-Solve ....................................................................................................................46c. Addressing Rumours in the Community ...........................................................................................................47 V. Summary of Key Points and Post-Test .................................................................................................481. Summary of Key Points ......................................................................................................................................482. Post-Test with Answers ......................................................................................................................................49 VI. Websites And Video Clips .....................................................................................................................531. Websites .............................................................................................................................................................532. Relevant Video Clips ...........................................................................................................................................53 Annexes: Information Cards ........................................................................................................................55Information Card 1 - Common Vaccine-Preventable Diseases ...........................................................................................55Information Card 2 - Frequently Asked Questions (FAQS) About Childhood Vaccinations .................................................58Information Card 3 - Simple Ways to Show Empathy ........................................................................................................62Information Card 4 - Responses that Encourage Communication ......................................................................................63Information Card 5 - Roadblocks to Communication ..........................................................................................................64Information Card 6 - Practical Communication Skills Case Study ....................................................................................65Information Card 7 - The CASE Approach ...........................................................................................................................66Information Card 8 - Steps to Address Negative Rumours in the Community ...................................................................67Information Card 9 - Reducing Pain ....................................................................................................................................68Information Card 10 - What is Community or Herd Immunity and Why is it Important? ....................................................70 Worksheets................ ..................................................................................................................................71 References................. ..................................................................................................................................73 6 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES KEY MESSAGES Why is this topic important to you? Vaccination is one of the worlds safest and most cost-effective public health interventions. Yet growing distrust in science, coupled with misinformation, means that vaccination coverage rates are declining in some countries and communities, resulting in an upsurge of vaccine-preventable diseases. The routine vaccination schedule brings families into frequent contact with the healthcare system, providing opportunities to reach children with life-saving vaccines and other crucial services for children and their families. Research shows that those caring for children tend to trust the advice of their health workers when it comes to vaccination, despite conflicting and often misleading information from other sources. That is why your role is so important: poor or disrespectful responses to caregivers and their concerns, coupled with a lack of uptake of vaccines (whether at a clinic or during a home visit), can have a strong and negative impact not only on their future demand for vaccination, but also for a whole range of other health services. As a professional who is trusted by the families you serve, you have a unique opportunity to identify vaccine-hesitant caregivers; understand their fears, dilemmas and choices; provide them with relevant information; help them overcome their vaccination hesitancy; strengthen their confidence in vaccines and immunization, and, in some instances, vaccinate their children. Using your communication skills and your knowledge about how individuals make behavioural choices, you can influence and guide parents to make decisions in the best interests of their children by listening to and understanding their concerns, providing answers to their questions, and helping them make the best choice for their child and their community. LEARNING OUTCOMES Once you have completed this module you will: Have a good understanding of vaccine-preventable diseases and the importance of immunization. Understand the role of health workers particularly home visitors in guiding families in their decisions to have their children protected against vaccine-preventable illnesses. Understand the importance of checking the immunization status of the child during each relevant visit and reminding caregivers about upcoming vaccination appointments. Understand that the views of caregivers range across a continuum from vaccine acceptance, to hesitancy and rejection, and that tailored approaches and actions are required from you to ensure that as many infants and children are protected against vaccine-preventable diseases as possible. Be able to apply evidence-based techniques and approaches to address hesitancy and influence caregivers decisions and behaviours. When checking a childs records, know how to give their caregivers the space to voice concerns and ask questions so that you can provide facts about vaccination benefits and address rumours and misinformation. Know how to identify caregivers who are hesitant about vaccines and respond to their questions and concerns with facts and empathy to help them make informed decisions and move towards vaccination. Communicate with caregivers who are rejecting vaccines in a respectful and empathetic way, reminding them that vaccines are safe, advising them of the dangers and symptoms of vaccine-preventable diseases, and reinforcing their responsibilities, as caregivers, to inform health workers if their child has not been vaccinated. Show your appreciation and validation of families that have accepted vaccination and that might be willing to become vaccine advocates in your community. Be able to advise parents on how to deal with the possible common side effects of vaccination. 7 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES PRE-TEST FOR THIS MODULE Some of these questions may refer to topics that are unfamiliar to you at this early stage, but do not worry. The module will cover all of these issues and features a post-test (with answers) at the end so that you can assess your own progress. 1. Costing studies have shown that childhood vaccinations constitute one of the most cost-effective public health interventions. True False 2. The number of parents refusing vaccinations for their infants and young children is increasing. This group should, therefore, be the main target for education by home visitors. True False 3. Increasing herd/community immunity is not a good argument for increased support for immunization programmes. True False 4. Several countries in Europe have had a high number of measles cases. Some of the reasons for this include (please mark all answers that apply): a. Shortages of measles vaccine in these countriesb. Caregivers who are complacent, because they do not know that measles is a dangerous and very infectious diseasec. Researchers who have been unable to dis-prove the myth that measles vaccine causes autismd. Measles brought in by travellers from poor, under-developed countriese. Falling immunization coverage. 5. The reason for vaccine hesitancy is simple: caregivers just lack the evidence about the benefits of vaccines. True False 6. Some of the strategies to overcome vaccine hesitancy among parents include (please mark all answers you consider correct):a. Improving the interpersonal and communication skills of health workersb. Listening to the concerns of caregivers and showing empathyc. Understanding how behaviour change takes place and using a solid behaviour-change approachd. Ensuring that health workers welcome caregivers who may feel socially excluded and stigmatizede. Telling caregivers that health professionals know best and that they should not question immunization, as they are not expertsf. Improving the quality of health services. 7. Some of the challenges to the achievement of high immunization coverage rates for measles and rubella coverage (please circle the answers you consider correct)a. The rejection of vaccines by some families in small communities and urban areas creates pools of unprotected children, increasing the risks of the rapid spread of epidemicsb. Measles vaccine is routinely provided to children when they are one year of age: a time when some caregivers may feel that their young children have already received enough vaccines to be protected MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 8 c. Lack of trust in vaccine safetyd. Shortage of vaccines in some countries as a result of recent epidemics. 8. Home visitors should be prepared to respond flexibly to the concerns of parents about vaccinations, with brief, tailored and fact-based elevator speeches (short enough to be presented during an elevator ride of just a few floors). True False 9. Polio has been eradicated and will soon be removed from all immunization schedules. True False 10. Arrange the following stages into the correct sequence for an expanded behaviour-change model: 11. List some non-verbal communication features you can use to make caregivers feel more comfortable: 12. Giving young infants multiple vaccines at the same time can overwhelm their immune system. True False 13. Naturally acquired immunity works better and is safer than vaccine-acquired immunity. True False 14. The following approaches need to be avoided when addressing the concerns of caregivers about vaccines (mark all that apply): a. Reflective listeningb. Solving any problems the caregiver has in getting to the clinicc. Empathy for their concerns about whether they are making the best decision for their childd. Praising them by telling them that they are your best parents and that you are so proud of theme. Rebuking caregivers for missing vaccination appointmentsf. Reminding caregivers that they are not experts and should not question immunization. Stages Step Decision Advocacy Pre-contemplation Maintenance Preparation Contemplation Trigger Fine-tuning Trial 9 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 9 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 15. Caregivers who refuse vaccines are likely to include individuals with some of the following characteristics (mark all that apply)a. They are from marginalized populationsb. They question science and are often highly educated c. They come from poor and uneducated families in urban areasd. They dont trust their health care system or health workers. 16. The three Cs are (mark all that apply) Complacency Concern Convenience Confidence. 17. Vaccination programmes are expensive because of the costs of vaccines, cold-chains and the salaries needed to deliver so many vaccines to so many children. It is an important public health intervention, but not very cost-effective. True False 18. 18. Measles is so dangerous because (mark all that apply)a. The disease kills most unvaccinated children because the vaccine only starts working when a child is around two years oldb. It is so infectious that herd community cannot be achievedc. It can wipe out much of the immune memory that a young child had acquired before contracting measlesd. Survivors of measles have an increased likelihood of death in the 2-3 years after contracting the diseasee. The infection spreads rapidly when a group of unvaccinated individuals is exposed to a case of measles. 19. There are no good sources of credible information about vaccines and vaccine safety. True False 20. Vaccine rejectors have a responsibility to inform health workers that their child has not been protected against vaccine-preventable diseases and should know about the signs and symptoms of these diseases. True False 21. While vaccination contributes primarily to Sustainable Development Goal 3 (SDG 3) on good health and wellbeing by reducing the number of vaccine-preventable deaths, it also contributes indirectly to many other SDGs. True False 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES GLOSSARY AND DEFINITIONS Caregiver. The parent or primary guardian of the child. This module uses the terms parent and caregiver interchangeably, recognizing that while most children are cared for by their parents, this is not always the case. For the purposes of this module, the terms parent or caregiver refer to the adults responsible for children and who make critical decisions on their behalf around immunization. Closed questions. Questions that are generally answered with a simple yes or no, in contrast to open-ended questions that encourage the other person to elaborate on their answer and encourage a genuine, two-way dialogue. Empathy. The capacity to understand or feel what another person is experiencing from their point of view, i.e. putting yourself in their shoes. This contrasts with sympathy, which often conveys pity for someone else, but not necessarily an understanding of their situation. European Centre for Disease Prevention and Control (ECDC). EU agency aimed at strengthening Europes defenses against infectious diseases. The core functions cover a wide spectrum of activities: surveillance, epidemic intelligence, response, scientific advice, microbiology, preparedness, public health training, international relations, health communication, and the scientific journal Eurosurveillance.1 Herd/community immunity. It is achieved when the vast majority of a population (at least 95% of children for childhood vaccination) is vaccinated, ensuring the protection of the whole community, including individuals who have not been vaccinated. Immunization. The process by which a person develops resistance to an infectious illness, usually through the application of a vaccine. Interpersonal communication. The exchange of information, thoughts, and feelings both verbal and non-verbal between two or more people that leads to dialogue, mutual understanding, respect for different perspectives and positions and immediate feedback. It can take place in a face-to-face setting or via video or audio settings by phone or Internet. MMR. Measles-mumps-rubella vaccine. Vaccination. Act of introducing a vaccine into the body to produce immunity to a disease. Vaccine hesitancy (WHO, 2019). The reluctance or refusal to vaccinate despite the availability of vaccines. Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines, and is influenced by multiple factors, such as complacency, convenience and confidence. 1 European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/en/about-ecdc https://www.ecdc.europa.eu/en/about-ecdc 11 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IINTRODUCTION 1. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing Recent decades have seen a surge of research on neuroscience and child development that has identified what newborns and young children need to survive, thrive, and lead healthy and productive lives. In May 2018, this critical body of scientific knowledge was brought together and used to create the Nurturing Care Framework by the World Health Organization (WHO), UNICEF, the World Bank and other partners. Compelling and robust scientific evidence was translated into five easily understandable and mutually supporting components that are essential for children to thrive (also shown in Figure 1): Good health Adequate nutrition Opportunities for early learning Responsive caregiving, and Security and safety. G OOD HEAL TH ADEQUATE NUTRITION G O PP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y R ESPO NSIV E C AR EG IVIN G Components of nurturing care Figure 1. The Nurturing Care: five interconnected components UNICEF/Kudravtsev 12 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES To survive, thrive and reach their full developmental potential, infants and young children need all five components of the Nurturing Care wheel. The components are not stand-alone, nor do they work as additions to each other: they are indivisible and synergistic. Responsive caregiving, for example, creates an enabling environment that can safeguard the other components: that is, a caregiver who is responsive to a child will be able to detect early signs that the child is feeling ill, tired, overwhelmed, anxious or threatened and will be able to respond in a way that protects the childs wellbeing. Similarly, a responsive caregiver is sensitive to the signs that a child is feeling well, alert, and ready to play and explore, and will be able to respond with appropriate activities. While parenting is perhaps the most challenging task for any adult, measures and support to prepare people for parenthood and education in parenting are more often available in high-and middle-income countries. Where such support is available in low-income countries, it tends to be accessed most frequently by high- and middle-income families. Families in many countries in the Europe and Central Asia region are fortunate to benefit from universal health care and home-visiting services provided by the public sector during the critical times of pregnancy and the first few years of a childs life. While the number of visits provided to all families is often limited, home visiting can be an effective entry point and opportunity to provide reliable and valid information and advice on child development, child rearing and parenting. Universal home-visiting services can also be used to identify families that are vulnerable or that need additional and targeted services. Providing all families with trusted and evidence-based information and advice and identifying the families with additional needs require knowledge and special skills in working with families from all walks of life to build a genuine and supportive partnership. About the resource package for home visitors and its modules The resource package for home visitors Supporting Families for Nurturing Care is a growing set of training modules (see Figure 2). It aims to strengthen the knowledge of home visitors on the key components of Nurturing Care, and enhance their skills in working with families to enable and empower them to provide the best start to their children. While targeting home visitors, many of these modules are also suitable for other health and non-health professionals who interact with pregnant women and the families of young children. Each of the modules responds to one or more components of Nurturing Care and builds capacity and skills needed by the home visitor to provide supportive home visits. In addition, each module aims to help home visitors reflect on professional attitudes and strengthen practices to engage inclusively and respectfully families that are diverse and face different needs and challenges. The modules have been developed by well-known experts and can be translated and adapted to different country contexts. In some countries, the modules have already become a mainstay of lifelong learning and continuing professional development for health workers and social-service providers engaged in promoting the comprehensive wellbeing of young children and their families. You can find hard copies of all modules on the International Step by Step Association (ISSA) website at https://www.issa.nl/modules_home_visitors and on UNICEF Agora. UNICEF/Voronin https://www.issa.nl/modules_home_visitors 13 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Knowledge Module 1: The Early Childhood Years - A Time of Endless Opportunities Module 7: Parental Wellbeing Module 11: Working against Stigma and Discrimination - Promoting Equity, Inclusion and Respect for Diversity Module 12: Children Who Develop Differently - Children with Disabilities or Developmental Difficulties Module 18: Gender Socialisation and Gender Dynamics in Families - The New Role of the Home Visitor Skills Module 2: The New Role of the Home Visitor Module 10: Caring and Empowering - Enhancing Communication Skills for Home Visitors Module 13: Developmental Monitoring and Screening Module 15: Working with Other Services Module 17: Supervision - Supporting Professionals and Enhancing Service Quality Module 22: Protecting Young Children from Vaccine-Preventable Diseases Figure 2. The Supporting Families for Nurturing Care resource package and its modules (asterisks indicate complementary pre-existing training packages) Components of nurturing care Thinking Healthy*Care for Child Development*Module 4: Falling in Love - Promoting Parent-Child AttachmentModule 5: Engaging Fathers Module 8: Common Parenting Concerns Integrated Management of Childhood Illnesses (IMCI)*Module 20: Healthy Weight, Physical Activity, Sleep and Sedentary TimeModule 21: The Care of Small and Sick NewbornsModule 22: Protecting Young Children from Vaccine-Preventable Diseases Module 6: The Art of Parenting - Love, Talk, Play, ReadModule 19: Early Childhood Education Programmmes Module 9: Home Environment and SafetyModule 14: Keeping Young Children Free from Violence, Abuse and Neglect Infant and Young Child Feeding (IYCF)*Baby-friendly Hospital Initiative (BFHI)Module 16: Responsive Feeding G OOD HEALT H ADEQUATE NUTRITIO NG OPP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y RE SPO NS IVE C AR EG IVIN G 14 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. Vaccination Trends Globally and in EuropeSince the development of the first vaccination against smallpox more than a century ago, vaccine programmes for children have become an integral component of preventive primary health care in every country on earth. Vaccination programmes prevent between 2 and 3 million deaths globally each year (WHO, 6.12.2019). In 2019, about 86 per cent of infants worldwide (116.3 million infants) received 3 doses of diphtheria- tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness, disability or death. Individuals and governments benefit from vast cost-savings as a result of the prevention of illness (EU and WHO, 2019). Based on the costs of illnesses, including treatment costs and productivity losses, that have been averted, every dollar invested in vaccines during the Decade of Vaccines (2011-2020) is estimated to have yielded a net return of about $16 (Ozawa et al., 2020). Two of the three strains of wild polio virus strains have been eradicated. A growing number of countries have achieved disease-free certifications (i.e. the European region has sustained its polio free status since 2002). The growing number of combination vaccines (i.e. the child is vaccinated against several diseases with one injection) is reducing the number of injections needed. In recent years, however, vaccination programmes have become victims of their own hard-earned success: few caregivers remember epidemics of polio, measles, pertussis or chickenpox that took the lives of many children, left many more with disabilities, and undermined their health and development. They may be unaware that measles is one of the worlds most contagious diseases, and that its transmission can only be halted if at least 95 per cent of the population is protected by immunization. In addition, misinformation that links vaccines to autism is easy to find and continues to circulate through social media and on websites, despite being discredited repeatedly, including by large-scale population studies (Hviid et al., 2019). Misinformation is sometimes disseminated deliberately to contradict (and appear alongside) evidence-based information about the benefits of vaccination. As a result of such challenges, countries around the world, and particularly in the Europe and Central Asia Region, have seen a resurgence of measles as the number of unprotected children and adults has grown. Measles cases have reached their highest level in Europe in 20 years (The Guardian, 21.12.2018). In total, 49 of the 53 countries in WHO European Region reported more than 192,943 measles cases and more than 100 measles-related deaths between 1 January 2018 and 31 December 2019, with a regional coverage with 2 doses of measles vaccination of only 91 per cent for the two doses of measles vaccination, which is too low to ensure herd immunity. Large disparities at the local level persist: some communities report over 95% coverage, and others below 70%. Several countries in the region Albania, the Czech Republic, Greece and the UK have recently lost their measles free certification. In the absence of disease, fear of disease has been replaced by fear of vaccines for some people (WHO, 2017). UNICEF/Bershadskyy Yuriy Immunization is one of the most cost-effective ways to save lives and promote good health and well-being. Every year, vaccines save 2-3 million lives, and millions more are protected from disease and disability. It routinely reaches more households than any other health service and brings communities into regular contact with the health system. This provides an effective platform to deliver other primary health care services and upon which to build universal health coverage. (Gavi The Vaccine Alliance, 2019) 15 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary UNICEF/ Krepkih Andrey Because of the frequency of the contact required with families, especially during the early months of a childs life, the quality of immunization services can either enhance or endanger the trust families place in health care services and professionals. As a health visitor for families with young children, you are in a unique position to educate the families you meet on the importance of vaccines and the vaccination schedule and identify caregivers who have some concerns or who may even reject vaccines. In their own home, and when talking to someone the family trusts their home visitor caregivers may feel more comfortable asking questions and voicing fears that have not been addressed during crowded vaccination sessions or in a busy doctors office. Your knowledge of the benefits and safety of vaccines, your communication skills and empathy for families, and your understanding of their concerns are your major tools for the promotion of this crucial health intervention. Once you have completed this module, you will be able to answer questions and provide practical tips to caregivers on how to support their child while they are being vaccinated and help them deal with common side effects. You will also be able to provide evidence-based information to counter any misinformation that might be spreading through the caregivers network or social media. Because you have the information about the childs vaccination status, you can tailor your response and refer families to other experts and specialists where necessary. The quality of your support is vital. It may influence whether caregivers complete the vaccination schedule for their children, and the way in which they engage with health services in the future. You may never know for sure, but you may have saved a childs life, while protecting other young children who cannot be vaccinated because of counter-indications, as well as infants who have not yet received their first vaccines! MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 16 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IIIMMUNIZATION AND VACCINE PREVENTABLE DISEASES A MAJOR PUBLIC HEALTH ACHIEVEMENT 1. Childhood Immunization In its listing of 100 objects that have shaped public health, Global Health NOW of the Johns Hopkins Bloomberg School of Public Health called immunization one of the most important public health achievements in human history.2 The development of vaccines has accelerated since the first use of a smallpox vaccine in 1798, and particularly since the middle of the 20th century. Today more than 30 infectious diseases can be prevented with vaccines (see Information Card 1 in annexes for information about common vaccine-preventable childhood diseases). Even though the worlds population has grown by almost 70 per cent, Gavi The Vaccine Alliance reports that cases of common vaccine preventable diseases have fallen by around 90 per cent (Gavi, 29.01.2019). Smallpox has been eradicated, as well as two of the three wild polio strains (WHO, 24.10.2019), and a number of countries have achieved measles-free status. Today, WHO recommends 10 vaccines during infancy and the early childhood years, plus one (for HPV) during adolescence recommendations that apply to every country (WHO, April 2019). Bacillus Calmette Guerin (BCG) (1 dose protects against tuberculosis) DTP-containing vaccine (3 doses protects against Diphtheria, Tetanus, and Pertussis Td (Tetanus and Diphtheria) booster at 9-15 yrs Hepatitis B (34 doses - protects against hepatitis type B) Hib (3 doses - prevents Haemophilus influenzae type b) Pneumococcal (3 doses - protects against pneumococcal disease) Polio (OPV and/or IPV, 34 doses - protects against poliomyelites) Rotavirus (23 doses - protects against rotavirus disease) Measles (2 doses - protects against measles) Rubella (1 dose - protects against rubella) HPV (2 doses - protects against human papilloma virus that can cause cervical and other types of cancer) (adolescent girls) Most of the countries in the ECA region use the MMR vaccine, a combined vaccine against measles, mumps and rubella. WHO recommends vaccination against mumps in high performing immunization programmes with the capacity to maintain coverage over 80% and where mumps reduction is a public health priority. Unfortunately, there has been a 30 per cent increase in cases of measles globally, and many countries in Europe and Central Asia have reported falling immunization coverage: half of the countries in the Region have DTP3 and MCV1 coverage below the 95 per cent minimum needed to ensure herd immunity. In 2019 WHO declared vaccine hesitancy as one out of 10 threats to global health. As we will discuss in more detail below, the WHO Vaccines Advisory Group has attributed this to the three Cs: Complacency, in-Convenience, and lack of Confidence, which contribute to vaccine hesitancy among parents and caregivers. Health workers, especially home visitors who work closely with their communities, have a critical role to play, as their advice is trusted by parents and can influence decisions around vaccination. To fulfil this role, however, home visitors need clear, factual information on vaccines, as well as communication tools to tackle the global threat to health posed by vaccine hesitancy (WHO, 2019). 2 Global Health NOW. One hundred objects that shaped public health. Retrieved from https://www.globalhealthnow.org/object/vaccines https://www.globalhealthnow.org/object/vaccines 17 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 17 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. How Vaccines WorkAs a home visitor, you often have very little time to cover a large range of relevant topics with the families you visit. That is why you need to be able to explain, in concise and understandable terms, how vaccines work and why it is important to vaccinate all children. To be efficient, apply the Elevator speech approach (Karam et al., 2019a, b) to make your most important points in the time that it would take for a ride in an elevator. It is important to tailor your messages to each family, taking into account their existing level of knowledge, as well as their concerns and attitudes around vaccination. Visuals can often be very powerful, helping you to make a point quickly and convincingly. Reflection and discussion There are many reasons why children are not vaccinated or vaccinated incompletely, but the following four steps can help you prepare short, clear responses to families that have concerns. First write down some of the questions and concerns you and your colleagues have heard from the caregivers you visit. Then choose several questions related to how vaccines work and develop brief elevator speeches with your colleagues or on your own. For your responses, use simple language, avoid jargon and technical terms; use analogies or simple examples and comparisons. Then try out your elevator speeches on others (family, caregivers, etc.) Finally, compare your responses to those provided by experts from WHO and the European Centre for Disease Prevention and Control (ECDC) and modify your elevator speeches as needed. Here are your practice questions: the kind of questions you may well be asked by the families you visit. Look through them and prepare some answers. When you have finished, compare your answers to the information provided in Box 1 below: How do vaccines work? Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Can vaccines cause the infection they are supposed to prevent? What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? I have heard that vaccinating my child also protects other children. What is community/ herd immunity and why is it important? UNICEF/Krepkih Andrey MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 18 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES How do vaccines work? Vaccines contain either a much-weakened form of the virus or bacterium that causes a disease, or a small part of it. When the body detects the contents of the vaccine, its immune system will produce the antibodies required to fight off infection and eliminate the disease-causing virus or bacterium. When a person later comes into contact with the virus or bacterium, the immune system will recognize it and protect the person by producing the right antibodies before any disease can be caused. (ECDC, Questions and answers about childhood vaccinations) Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Infants and young children are vaccinated in controlled settings (doctors offices or clinics), and parents are informed about possible side effects, how to manage these, and when to seek additional advice. With vaccines, the immune system is stimulated to develop protection without infection, hence it is more effective (WHO, 2017). The only way a child can acquire natural immunity is to become sick with the disease itself. Even when the impact on the child is mild, it may mean additional caregiving and expenses for some families. But the disease could also result in complications, long-term illness, disability and even death, and many other children may become exposed in the process. For measles, the Center for Disease Control and Prevention (CDC) has reported complications with 30 per cent of measles cases, most commonly diarrhoea, ear infections and pneumonia. For every 1,000 cases of measles, one child may also be affected by encephalitis and two may die. Whats more, the measles infection can destroy much of the wider immunity a child has built up, increasing their risk of contracting other diseases. Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Newborns commonly manage many challenges to their immune systems at the same time. The mothers womb is free from bacteria and viruses, so newborns immediately face a host of different challenges to their immune systems. From the moment of birth, thousands of different bacteria start to live on the surface of the intestines. By quickly making immune responses to these bacteria, babies keep them from invading the bloodstream and causing serious diseases. In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunological cells circulating in their bodies. Therefore, vaccines given in the first two years of life are a drop in the ocean of what an infants immune system successfully encounters and manages every day. (ECDC. Questions and answers about childhood vaccinations) Can vaccines cause the infection they are supposed to prevent? Inactivated vaccines do not have live germs and cannot cause infections. Live vaccines have weakened germs that are unable to cause disease in healthy people. Rarely a mild form of infection may occur. (WHO, 2017) What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? The defences of children who have survived a vaccine preventable-disease are not necessarily stronger. On the contrary, the disease tends to make the child weaker and more vulnerable. Recent research on measles has shown that having suffered and survived this deadly disease may make it harder for a child to fight other infections for years to come. It has been known for some time that children who had measles were 2-3 times more likely to die from pneumonia, diarrhoea or other conditions in subsequent years. Now, we have learned that the measles virus infects and destroys memory B-cells. These are the cells where the immune system stores information about past Box 1. How vaccines work https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html https://www.ecdc.europa.eu/en/immunisation-vaccines/childhood-vaccination/faq?pdf=yes&preview=yes 19 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 19 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES infections that can help it in fighting new infections. In addition, the measles virus also reduces the ability of the immune system to respond to new and dangerous pathogens. It now seems possible that there could be actually five times more indirect deaths from immune amnesia (caused by the measles virus) than the initial infection caused. (Gallagher, 2019) I have heard that vaccinating my child also protects other children. What is community/herd immunity and why is it important? Vaccination protects you and your family, and it also helps protect others. It contributes to community immunity. This is achieved when enough people in a population are immune to an infectious disease (through vaccination and/or prior illness) so that it is unlikely to spread from person to person. Even those who cannot be vaccinated because they are too young, are allergic to vaccine components, or vaccination is contraindicated for them, are offered some protection because the disease cannot spread in the community and infect them. This is also known as herd or community immunity. When more than 95% of population is (blue dots) in a community they can protect those who are not yet vaccinated (yellow dots) from those who are infectious (red dots) When groups of unvaccinated people build up and are in close proximity, community immunity doesnt work and the disease spreads. For additional brief answers to common questions and concerns (developed by WHO and ECDC communication experts), check Information Card 2 Frequently Asked Questions (FAQs) about Childhood Vaccinations (in annexes), which also includes links to additional information. However, keep in mind that you will have to tailor your answers to the needs of individual families, their attitudes towards vaccination, and level of knowledge, so just learning some standardized answers by heart is not enough. 20 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 20 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. The Benefits of Vaccination to the Individual Child and Society NOPOVERTY AFFORDABLE ANDCLEAN ENERGY CLIMATEACTION LIFE BELOWWATER LIFE ON LAND PARTNERSHIPSFOR THE GOALS DECENT WORK ANDECONOMIC GROWTH SUSTAINABLE CITIESAND COMMUNITIES ZEROHUNGER EDUCATIONQUALITY EQUALITYGENDER AND SANITATIONCLEAN WATER PEACE, JUSTICEAnd STRONG INSTITUTIONS RESPONSIBLECONSUMPTIONAND PRODUCTION GOOD HEALTHAND WELL-BEING INDUSTRY, INNOVATIONAND INFRASTRUCTURE REDUCED INEQUALITIES GLO BA L S TRA TEGY FOR WOME NS, CHILDRENS AND ADO LESCEN TS HEA LTH SU RVIV E TH RIV E TRANSFORM Figure 3. Sustainable Development Goals (SDGs) Reflection and discussion Immunization for vaccine-preventable diseases provides one of the strongest financial returns of any public health intervention, but its benefits go far beyond the health sector alone. Take a look at Figure 3, which sets out all of the Sustainable Development Goals. Can you list ways in which the benefits of immunization can be felt across all of these goals? To help you, the potential links between immunization and the SDGs are set out in Table 1: perhaps you can think of others! When you see how vaccination supports the achievement of the SDGs, you can feel confident and proud in promoting such a cost-effective and safe service to your community and to the families you serve. Immunizing children is one of public healths best buys. Vaccines are relatively easy to deliver and, in most cases, provide lifelong protection. They boost development both through direct medical savings and indirect economic benefits such as cognitive development, educational attainment, labour productivity, income, savings and investment (Gavi The Vaccine Alliance, 2019) https://www.gavi.org/vaccineswork/value-vaccination https://www.gavi.org/vaccineswork/value-vaccination 21 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Sustainable Development Goal Vaccination programmes 1. No povertyPrevent expensive illnesses and associated health-care costs, reducing the number of people forced into poverty. 2. Zero hungerProtect childrens nutritional status, because illness impairs absorption of essential nutrients. Malnourished children are also at a higher risk of death from vaccine-preventable diseases. 3. Good health and wellbeing Reduce mortality and morbidity and provide the platform for the delivery of other health services. 4. Quality educationVaccinated children have better nutrition and health status, and have, therefore, better chances to learn and achieve. 5. Gender equalityGlobally, this is a gender-equal intervention, with similar rates of vaccination for girls and boys 6. Clean water and sanitation (WASH) Prevent diarrhoeal diseases, alongside WASH programming. 8. Decent work and economic growth Contribute to the growth of healthy children who attain education and become a productive workforce. Caregivers are more likely to be able to work when children are not affected by vaccine-preventable diseases. 10. Reduce inequalityProtect all communities and children, including the most marginalized, those living in rural areas and in conflict zones, which can be further devastated by epidemics of infectious disease. 11. Healthy citiesProtect children from increased risk of exposure to vaccine-preventable diseases in cities where infections are more able to spread quickly. 16. Peace, justice and strong institution Contribute to equity and strong health services. Table 1. Vaccination and the achievement of the Sustainable Development Goals (SDGs) Source: Gavi, 2019 UNICEF/ Krepkih Andrey 4. Vaccine Safety and Side Effects Before you respond to concerns about the safety of vaccines in general

MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 3 The Report has been prepared by the Danish Refugee Council-Danish Demining Group (DRC-DDG) in Ukraine with the support of the United Nations Childrens Fund (UNICEF). The information contained in this report was obtained and analysed in good faith and is accurate to the best of DRC-DDGs knowledge. Conclusions and opinions expressed in this report do not necessarily reflect the official position of UNICEF. The report has been prepared for use by DRC-DDG and UNICEF. The contents of this report may include some confidential and sensitive data. Any further dissemination of information enclosed is to be agreed by both parties in advance. ABOUT THE ORGANIZATIONS The Danish Refugee Council (DRC) is an international humanitarian non-governmental and non-profit organi-zation operating in 35 countries. DRCs mandate includes the implementation of protection programmes, assis-tance, and promotion of long-term solutions for refugees and internally displaced persons as well as other popula-tion groups affected by conflicts or natural disasters. The DRC has operated in Ukraine since June 2007. In January 2013, the programme for the protection of refugees and asylum-seekers and strengthening of government and civil society capacities ended. In 2014, the DRC returned to Ukraine to provide immediate support to internally displaced people and affected civilians in eastern Ukraine. The DRC headquarters in Ukraine are located in Kyiv. Program offices are located in Mariupol, Sloviansk, Severodonetsk and Berdyansk. DDG is a specialist unit operating within DRC to protect civilians from the harmful effects of landmines and other explosive remnants of war (ERW). DDG has been operating in Ukraine since November 2014, with operations focussed in the east of the country. The United Nations Childrens Fund (UNICEF) works across 190 countries and territories to reach the children and young people who are most at risk and most in need. We work to save their lives. To protect their rights. To keep them safe from harm. To give them a childhood in which they are protected, healthy, and educated. To give them a fair chance to fulfil their potential, so that someday, they can build a better world. UNICEF opened its office in Kyiv in 1997. Over the years, UNICEF has supported the Government of Ukraine to develop health, water and sanitation, education and protection programmes for children. Since the beginning of the conflict in eastern Ukraine, UNICEF works to fulfill the core commitments for children in humanitarian action, including access to education, psychosocial support, water and sanitation, mine risk education, maternal and child health and HIV and AIDS services. This publication was produced with the financial support of the German Government. Its contents do not necessarily reflect the views of the German Government. MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT4 MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 5 CONTENTS LIST OF ACRONYMS 7 EXECUTIVE SUMMARY 8 INTRODUCTION 9 Background 10 Setting the context: key data 11 METHODOLOGY 12 LIMITATIONS 14 KEY FINDINGS 15 Analysis child mine/erw survivors 18 Analysis by age and gender 18 Analysis by geography 19 Analysis by type of item and cause of accident 20 Analysis by type of injury 21 Analysis by social profile and economic impact 22 Analysis: needs and barriers to assistance for child mine/erw survivors 24 Emergency and continuing medical care 24 Physical and other rehabilitation 25 Psychological and psychosocial support 26 Social (and economic inclusion) 27 Laws and public policies 29 Analysis: stakeholders and services 30 Data collection 31 Emergency and continuing medical care 34 Physical and other rehabilitation 36 Psychological and psycho-social support 39 Social and economic inclusion 41 Laws and public policies 43 CONCLUSIONS AND RECOMMENDATIONS 44 Data collection 44 Emergency and ongoing medical care 45 Physical and other rehabilitation 46 Psychological and psychosocial support 46 Social and economic inclusion 47 Laws and public policies 47 Conclusions paper 48 MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 7 LIST OF ACRONYMS CAS Child Affairs Services CIMIC Civil-Military Cooperation Group DDG Danish Demining Group DOE Department of Education DOH Department of Health DOSP Department of Social Protection DRC Danish Refugee Council ERW Explosive Remnants of War GCA Government-controlled Area ICRC International Committee of the Red Cross IED Improvised Explosive Device MOD Ministry of Defence MOE Ministry of Education MOH Ministry of Health MOIA Ministry of Internal Affairs MTOT Ministry of Temporarily Occupied Territories and Internally Displaced Persons NGCA Non-government-controlled Area NGO Non-governmental Organization OSCE Organization for Security and Co-operation in Europe SES State Emergency Service UNICEF United Nations Children's Fund UXO Unexploded Ordnance WHO World Health Organization MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT8 Concerted efforts, albeit relatively modest, are now being directed towards the issue of explosive hazard contamination, as it continues to climb higher on the agenda of the Government of Ukraine. The rising prominence of the landmine issue has been underscored lately by the passing of specific legislation on mine action (Law 9080/01 of 6 December 2018) as well as an official request by the Government of Ukraine for an extension to the deadline by which it must meet its obligations under the Anti-Personnel Landmine Ban Treaty (Ottawa Treaty). Whilst the mine action sector is gathering momentum in terms of funding for risk education programmes and clearance operations, a key area that is currently being overlooked by the government and the donor community alike is that of mine victim assistance. This preliminary needs assessment covers mine victim assistance in Ukraine. It focuses mainly on child victims and is a synthesis of primary data, reports, and key informant interviews collected from field level through to government level, coming directly from victims of mines/ERW themselves, social services, government administrations at district and regional level and national / international NGOs. The assessment was conducted between September and November 2018 in government-controlled areas of Donetsk and Luhansk oblasts, and in Kyiv. The assessment was supported by UNICEF and the Government of Germany and conducted by the Danish Refugee Council Danish Demining Group (DRC-DDG). It was made possible by: The willingness and help of families of child mine/ERW survivors, who shared their life stories and experience; The work of DRC-DDG interviewers, who travelled long distances to find the survivors and communicated with the families of child mine/ERW survivors with care and empathy; and The support received from the authorities, NGOs and volunteers at state, regional and local levels who helped to identify the survivors and facilitate referrals. The findings of this assessment point to gaps across the all the key areas of mine victim assistance as defined in the United Nations Policy on Victim Assistance in Mine Action. Common themes present themselves throughout the analysis, such as a clear and urgent need for a centralized and standardized system for the collection, maintenance and analysis of data on mine victims, as well as a need for a more co-ordinated and less bureaucratic system of treatment for victims, from the moment of the accident through to final recovery. By first collecting and analysing data from existing child mine/ERW victims in Ukraine and then evaluating the environment for victim assistance by examining the services available and interacting directly with relevant ministries and stakeholders, DRC-DDG was able to arrive at a number of conclusions and recommendations formed from the exercise, to a level of detail and thoroughness that does not appear to have been previously been made on the topic in Ukraine. While certain limitations are recognized within the report (mainly arising from time, resources and the necessity to focus mainly on child victims), DRC-DDG is confident that this assessment provides a good overall picture of the current state of the mine/ERW victim assistance environment within Ukraine, as well as areas for its development and expansion. EXECUTIVE SUMMARY As a direct result of the ongoing conflict in eastern Ukraine, large swathes of the Donbas region, on both sides of the contact line, have become contaminated with landmines and explosive remnants of war (ERW). The number and frequency of civilian casualties as a result of this contamination has propelled Ukraine into the unenviable position of one of the most mine-affected countries in the world. MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 9 The objective of the report is to present the current situa-tion of child mine/ERW survivors and their families in terms of their path from accident to recovery, and to identify the outstanding needs in this process. In parallel, the report shows the capacity of governmental and non-governmental structures to provide support to child mine/ERW survivors. The assessment aims to identify how current programming in Ukraine can best address needs, according to the mine victim assistance pillars identified in international best practice. The results of this needs assessment will inform the devel-opment of further steps in mine victim assistance program-ming in Ukraine and provide recommendations for eliminat-ing gaps and strengthening existing capacities. To implement this needs assessment of child mine/ERW victims and to prepare the report, DRC-DDG was guided by International Mine Action Standards, the United Nations Policy on Victim Assistance in Mine Action, and Assistance to Victims of Land Mines and Explosive Remnants of War: Guidance on Child Focused Victim Assistance (UNICEF). According to the United Nations Policy on Victim Assistance in Mine Action, Mine Victim Assistance is based on the fol-lowing six spheres: 🅐 Data collection, including contextual analysis and a needs assessment, as a starting point, to understand the extent of the problem and anticipated challenges in addressing it; 🅑 Emergency and continuing medical care, including emergency first aid to the victim of the explosion and ongoing medical care other than physical rehabilitation; 🅒 Physical and other rehabilitation, including physiotherapy, as well as assistive and mobility devices; 🅓 Psychological and psychosocial support; 🅔 Social and economic inclusion, inclusive education, as well as access to basic services and disability awareness; and 🅕 Establishment, enforcement and implementation of relevant laws and public policies. It is important to acknowledge that the policy emphasizes a comprehensive approach to mine victim assistance, ena-bling victims to realize their human rights. The above-men-tioned spheres should not be seen as separate sets of actions. They form the basis for a holistic and integrated approach to realization of the human rights of mine/ERW victims. In the context of the United Nations Policy on Mine Action, the term victim refers to a person who has suffered physical, emotional and psychological injury, economic loss or substantial impairment of his or her fundamental rights through acts or omissions related to the use of mines or the presence of ERW. Victims include directly impacted individ-uals (including persons injured and killed); their families; and communities affected by mines, ERW, cluster munitions or improvised explosive devices (IEDs) following conflict. The term survivor refers to a person who was harmed or injured as a result of a mine, ERW, cluster munition or IED accident and has survived the accident. 1 1 UN Policy on Victim Assistance in Mine Action (2016) INTRODUCTION MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT10 The issue of contamination from explosive remnants of war (ERW) is not new to Ukraine. Since World War II, which saw large swathes of Ukraine fought over, Ukrainian police, mili-tary and civil defence units have consistently been engaged in clearing the remnants of war in order to protect the lives of civilians from unexploded and potentially unstable ordnance. However, Ukrainians now face an additional threat: one which has come about as a result of recent hostilities in the east of the county and which involves decidedly more mod-ern and more powerful weapons of war. Large areas of the Donbas region are now contaminated by the explosive rem-nants of a more recent conflict, including landmines, which are understood to have been laid on an industrial scale during the fighting of the last four years, placing Ukraine amongst the most mine-affected countries in the world, alongside countries such as Afghanistan, Syria and Iraq. Owing to the evolution of their design and manufacture, modern landmines (as well as items such as grenades that can effectively be deployed as victim-operated devices through the use of tripwires, for example) are able to re-main in position and functional for decades, posing a threat to the lives of civilians long after fighting may have ceased in these areas. Ukraine is now realizing the devastating effects of such weapons with over 1,500 casualties of land-mines and unexploded ordnance (UXO) recorded since the beginning of the current conflict in 2014. With the conflict now having entered a low-intensity phase, casualties arising from landmines/UXO are now regularly greater than those as a result of direct conflict. Ironically, as the intensity of the conflict further de-escalates and displaced persons are able to return to their former places of residence in higher numbers, DRC-DDG fully expects the casualty rates from landmines/UXO to increase. Since the start of the conflict, between June 2014 and Oc-tober 2018, a total of 827 mine/explosive remnants of war (ERW) accidents were recorded by DDG from open sources. Of the 1,582 casualties, 119 were children (73 mine/ERW accidents), of whom 105 child victims (64 accidents) were in Luhansk and Donetsk oblasts (65 per cent in non-govern-ment-controlled areas). The clearance of landmines and UXO is a resource-heavy, intensive and painstaking process requiring the mobiliza-tion of significant amounts of funding, machinery and hu-man capital. It is imperative, therefore, that while clearance efforts are underway, parallel support should be provided for those who continue to suffer the consequences of landmines/UXO, specifically those who receive grievous injuries through no fault of their own and must suffer the consequences for the rest of their lives. Victim assistance (VA) therefore is recognized in inter-national best practice as one of the five core activities or pillars that should be pursued and developed by the gov-ernments of countries that are affected by landmine/UXO contamination, in proportion to the scale of the problem. Governments of affected countries should maintain clear visibility on how landmines/UXO are affecting the popu-lation, and make every effort to compensate civilians for damages sustained as a result of contamination. Further-more, governments that have committed to the Interna-tional Anti-Personnel Mine Ban Treaty, such as the Gov-ernment of Ukraine, are all the more obliged to maintain visibility on issues pertaining to landmine contamination and progress towards compliance with treaty obligations, including commitments to clear all known contaminated lands as well as to appropriately care for individuals that suffer as a result of mines. While the mine action sector in Ukraine is still in the early stages of development, DRC-DDG and UNICEF intend to support the Government and accelerate progress towards adoption of international standards across key areas, includ-ing, crucially, mine victim assistance. By working to identify the needs, gaps and opportunities for further development within mine victim assistance, DRC-DDG and UNICEF aim to work with the Government and international community to bring a wider and higher standard of care to those who need it the most. BACKGROUND MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 11 Ukraine ranks among the most severely affected places in the world for casualties as a result of landmines and other explosive remnants of war (ERW) after two world wars and the continuing conflict in the east.2 Landmines, ERWs and unexploded ordnance (UXO) were the leading cause of conflict-related child casualties in Ukraine in 2017, accounting for about two-thirds of all recorded deaths and injuries and leaving many children with lifelong disabilities. Ukraine signed the Mine Ban Treaty on 24 Feb-ruary 1999 and ratified it on 27 December 2005, becoming a State Party on 1 June 2006. The Ministry of Education and Science has de-veloped and approved the Concept of the New Ukrainian School, a strategy for reforming second-ary education by 2029. Ukraine is yet to endorse the Safe Schools Decla-ration: the Ministry of Education and Science in Ukraine has communicated plans to submit rele-vant documentation to the Cabinet of Ministers to proceed. 2 Landmine Monitor 2017 As of 2017, only 2.5 per cent of the total health budget is dedicated to mental health, and the majority of this funding (89 per cent) goes toward inpatient mental health care.3 Most people with common mental disorders (up to 75 per cent) do not access adequate mental health care. Stigma and discrimination, fear of having a public record, and availability of services are major barriers.4 The Government has adopted the National Action Plan for Implementation of the Convention on the Rights of Persons with Disabilities for the period until 2020. Harmonization of national legislation with European human rights standards is in pro-cess. Ukraine signed the Convention on the Rights of Persons with Disabilities on 24 September 2008 and ratified it on 4 February 2010. 3 Mental health in transition Report, World Bank Group, 2017 4 Mental health in transition Report, World Bank Group, 2017 SETTING THE CONTEXT: KEY DATA MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT12 Tools and data collection In order to provide an overview of the current situation of child mine/ERW victims, their families, existing needs, access to services in conflict-affected areas, existing service providers, legislative frameworks and mechanisms for mine victim assistance in Ukraine and gaps in covering child mine/ERW victims needs, a combination of quantitative and qual-itative methods was used. The needs assessment includes both primary and secondary data sources. Primary data was collected directly at commu-nity level by DRC-DDG (key informant interviews and house-holds interviews). Secondary data was derived from other sources, such as the DDG mine action database and reports, institutional and governmental sources (laws, resolutions, orders and so on), as well as a comprehensive desk review of existing material produced by other humanitarian actors. In order to achieve wide coverage, DRC-DDG consulted and collaborated with a wide range of other actors. Quantitative data collection tools A questionnaire was developed to collect quantitative data through household (HH) interviews. It was partly based on questionnaires developed by humanitarian agencies and used to assess the needs and situation of mine victims in Azerbaijan, Mozambique and Myanmar. The questionnaire was finalized and validated based on input from the MEAL department of DRC-DDG Ukraine. It was then used in per-sonal interviews with respondents. Data disaggregation (age, sex, location and so on) were taken into account when developing methods for data collection and recording. Team members were trained before the start of the assessment on interviewing techniques, ethics, disability and victims issues, rules and practical application of the questionnaire. Household interviews were carried out in the preferred language of the respondents (Ukrainian or Russian). Qualitative data collection tools In order to measure the level of inclusion of child mine/ERW victims and their families, other actors in the commu-nity, including public and private institutions (local NGOs and local authorities) as well as service providers (hospitals, schools and social services) were interviewed. Key inform-ant interviews (KIIs) focused on the six elements of mine victim assistance. A questionnaire was designed to collect qualitative data through KIIs. It was finalized with a review by the MEAL de-partment. All notes during KIIs were recorded in a reporting format for further analysis. DRC-DDG conducted meetings at national level with the Ministry of Temporarily Occupied Territories and IDPs of Ukraine (MTOT), the Ministry of Social Policy (MSP), the Min-istry of Health (MoH), the Ministry of Education (MoE), the State Service for War Veterans Affairs, the Commissioner for Observance of the Human Rights of the Verkhovna Rada (Ombudsman), the State Emergency Service of Ukraine and two national experts on child protection. In Luhansk and Donetsk, district level meetings were held with the Child Affairs Services (CAS); the Department of Civil Protection, the Centre for Social Services for Families, Children and Youth; the Department of Education; the Department of Health; the National Police; the Juvenile Police; Lysychansk Childrens Hospital, Department Head of State Emergency Service in Donetsk Oblast; and the Department of Social Protection. At the local level, meetings were held with the Social Protection Unit in Volnovakha Rayon, Stanichno-Lu-hanska Rayon Administration, Svatovo Rayon Hospital, , Mykolske Child Affairs Service, Mykolske Village Council, Zlatoustivka Village Council, Krasnohorivka Village Coun-cil, Zorya Village Council, the Inclusive Resource Centre in Volnovakha, Volnovakha Rayon Rehabilitation Centre for Children with Disabilities, Kurahove Town Hospital, Krasno-horivka Hospital, the School in Zlatoustivka, the School in Hranitne, and the School in Berestove. Other stakeholders met included local NGOs (Proliska, Pomozhem and Divis Certsem), international NGOs (Save the Children, SOS Chil-drens Villages), and international entities (ICRC, the United Nations Education Cluster, WHO and the OSCE). Geographical area of assessment The needs assessment of child mine/ERW survivors (HH interviews) was implemented in government-controlled areas of Donetsk and Luhansk oblasts. These two areas were selected because they are in very close proximity to the contact line/military conflict, and therefore are amongst the most heavily impacted territories with the highest number of mine/ERW accidents. Within each oblast the following locations were selected: Donetsk Oblast: Mykolskyi, Volnovakhskyi, Maryinskyi, Kostiantynivskyi and Bahmutskyi Districts. Luhansk Oblast: Stanychno-Luhanskyi, Popasnyanskyi, Bilovodskyi and Svativskyi Districts. The selection of districts was based on history of mine/ERW contamination and programme planning criteria, such as good access and safety. METHODOLOGY MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 13 KIIs were carried out in Kyiv and districts of Donetsk and Luhansk oblasts where HH interviews were conducted. Population and sample size The specific target population was child mine/ERW accident survivors and their caregivers. The sample size for household interviews was based on the assumption that the number of child mine/ERW survivors interviews was representative of the overall number of survivors in the two oblasts selected for the assessment. At least 50 per cent of HHs in the study area with mine/ERW survivors were visited. Sampling criteria: Child mine/ERW victims were identified based on snowball sampling/chain referral sampling methods. Various actors were asked to identify child mine/ERW victims, including community leaders, local community members, service providers, governmental and non-governmental organizations, and families of child mine/ERW victims themselves. The chief research population comprised 15 households, including 16 child mine/ERW survivors and one adult mine/ERW survivor who was 17 years old at the time of the mine accident and 21 years old at the time of interview. The sample size of stakeholders was identified by the number of acting service providers at three levels: country, oblast and local, taking into account the six victim assistance pillars. In total, 52 stakeholders were covered by the assessment. Data analysis Secondary analysis/desk review was conducted as part of the data analysis after all the data had been compiled. This was an integral part of a situational analysis, and was followed by analysis of the primary data (assessment of results). Statistical analysis was conducted of the quantita-tive data gathered (graphs and charts to visualize numbers) coupled with qualitative analysis of the interviews con-ducted to identify clear needs, thematic issues and avail-able resources/services. The use of mixed data collection techniques allowed for the triangulation of information sources and provided valuable insights and inferences from the statistics. The data analysis aimed to correspond to the objective of the needs assessment: to obtain a comprehensive picture of mine victims problems in order to guide the planning and development of future interventions, and answer the key questions: What are the most urgent needs of mine victims? Which assistance/services are provided and by whom? What data on mine victims are available? What are the gaps and areas for improvement in the current context? What are the most appropriate ways/tools to bridge the gaps? The DRC-DDG team developed an analysis matrix, organ-izing the assessment questions and identifying indicators that would help address the questions and indicate poten-tial data sources, forming the basis for data analysis. Needs analysis involved a logical accumulation of facts in terms of the communities expressed needs and existing provision of facilities and services. Due to time constraints, this was fol-lowed by a group working session in which staff members identified ways to incorporate the data into this report. Principles and ethics During planning, implementation and reporting, DRCDDG ensured the following principles: Participatory approach: participants and stakeholders have access to the assessment findings. The Do No Harm principle is strictly adhered to in all situations. The intended benefit to the assessment participants was balanced against the risks involved in conducting the assess-ments. This includes interviewers being mindful of potential trauma to the informants; the likely unintended consequenc-es of participation for informants; confidentiality in the space of consultation; and the length of time for consultation. Additionally, DRC-DDG followed enumerator ethics: At the start of each interview, the assessment team explained the purpose of the assessment and asked for the consent of the respondent. An informed consent form was obtained by DRC-DDGs enumerator team. The families of child mine/ERW survivors who took part in HH interviews had the right to refuse to participate or to choose to discontinue the interview at any time. Expectations of receiving any kind of assistance due to participating in the assessment were carefully managed by the team. The enumerator team emphasized during the assessment that participation would not result in immediate benefits, but rather that the responses would allow for the development of a child mine/ERW victim assistance response to benefit mine/ERW victims in general. MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT14 Limited timeframe The needs assessment timeframe was just three months, making it challenging to secure interviews with families and stakeholders located in the two oblasts and Kyiv (for the country level KIIs with government representatives). As a result, the data collection period overlapped partially with the analysis and report writing phase. However, the analytical approach described above enabled the team to ensure a robust and documented process from interviews to findings and conclusions. It is important to note that this is not an in-depth needs assessment due to the short timeframe for conducting the assessment. To receive a more comprehensive picture of the needs and capabilities of mine/ERW survivors and their families, a thorough analysis against mine victim assistance elements should be conducted. See the Recommendations section for further discussion. Geographical spread The team had intended to be able to conduct more house-hold interviews with mine/ERW survivors. However, be-cause of time limitations, security challenges, the small size of the team, the very large area to cover, and the logistical challenges of travelling in conflict-affected areas, the team was only able to meet 15 families of child mine/ERW survi-vors. This limitation had to be accepted within the scope of the assessment. Availability of data Due to the absence of an existing data base containing the requisite details child mine/ERW victims, DRC-DDG faced difficulties identifying child mine/ERW survivors. DRC-DDG requested information about the children from Child Affairs Services and Centres of Social Services in Donetsk and Luhansk oblasts. However, the information provided was often mixed with all conflict-related accidents (includ-ing shooting and shelling). DRC-DDG used its own internal mine/ERW statistics and database to map all known cases of child mine/ERW accidents and casualties, ultimately having to investigate and verify each case from a number of sources: this took considerable time and additional effort. Quality of data The human factor plays a key role in terms of information received and findings in this report. DRC-DDG faced a num-ber of confusions due to contradiction of information pro-vided by the representatives of certain main stakeholders. At the time of drafting this report, DRC-DDG is continuing to identify and cross-check points of contradictory data. Demographic limitations The assessment only targeted child mine/ERW survivors, though a number child mine/ERW survivors had already reached adulthood at the time of assessment. It is impor-tant to note that the vast majority of all mine/ERW victims are adult males (79 per cent). Limitations of scope The assessment did not include fatal casualties and the needs of their families. As a result, data from the families of the deceased did not inform the assessment on access to services (e.g. emergency care and psychological support). As explained above, the needs assessment had a small target group. Each case is individual and while DRC-DDG can make generalizations, making assumptions from such a limited sample size is problematic. DRC-DDG initially planned to analyse the rate of satisfaction with services received by child mine/ERW survivors and their families. However, when proceeding with the needs assessment, it was clear that currently, this is not feasible for several reasons. Generally, people have no means of comparison, having not previously received assistance under a victim assistance programme. If their child survived, there was a tendency for families to view this as adequate assistance (i.e. emergency assistance only), not being aware of their rights and entitlements to other types of assistance that could and should be available to such victims. LIMITATIONS This section outlines the challenges that the evaluation team encountered. MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 15 OVERVIEW To arrive at the key findings, DRC-DDG conducted two lines of assessment in parallel. The first line involved the collection and analysis of concrete, primary data directly from child mine/ERW victims and their caregivers, whilst the second line of assessment aimed to achieve a full understanding of the wider situation with regard to existing stakeholders and service providers. In order to gain an accurate understanding of the profile of child mine/ERW victims, DRC-DDG identified 39 cases of child mine/ERW casualties in Donetsk and Luhansk oblasts (18 and 21 casualties respectively), through a combination of open sources that were independently verified. Of these 39 casualties, DRC-DDG interviewed 17 victims, using the results for the analysis below. According to the information obtained by DRC-DDG, of the remaining 22 casualties identified, six had deceased as a result of their accidents, three were already over the age of 18, one had moved to another oblast and 12 were not interviewed by DRC-DDG due to the limitations outlined above. The analysis of the primary data collected from the 17 child mine/ERW victims is intended first to form a profile of the child mine/ERW victims in terms of factors such as gender/age, geography and type of injury, and second to review the access, needs and barriers to the pillars of victim assistance as identified through interaction with the victims themselves. In parallel with the collection and analysis of the prima-ry data from child victims, DRC-DDG conducted 52 key informant interviews with a wide variety of stakehold-ers, including government ministries, administrations (both local and regional), as well as local and interna-tional NGOs, arriving at an informed view of the services available, potential gaps and recommendations to cover unmet needs. KEY FINDINGS A stand in the school hallway in Hranitne. Half of the information materials are dedicated to mine risk education, exemplifying the importance that schools near the contact line place on this issue. MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT16 LEGEND Line of Contact UA Control Area of high concern Territory of Ukraine Non-Government Controlled Area (NGCA) 15 km Zone DRC/DDG Office Number of child victims District with child casualitiesmine/ERW accidents Line of Contact OAG Control Oblast boundary 1 SEA OF AZOV Kostiantynivka SLOVYANSK Pokrovsk Bahmutskuy BilovodskiyStarobilskyi Svativskiy Volnovaskyi DokuchaevskVuhledar SEVERODONETSKLysychansk Luhansk Donetsk MARIUPOL Marinskyi Yasynuvate Popasnianskyi HorlivkaToretsk Antracyd Sorokynskyi Sloviyanoserbskiy Sverdlovsk Snizhnyansk Shahtarskyi Khartsyzk Krasnyi Luch Yenakievska Debaltsevo Perevalskyi DONETSK OBLAST LUHANSKOBLAST Nikolskyi StanychnoLuhanskiy 11 117 6 6 5 4 3 3 3 1 1 1 1 4 4 4 6 K8 1 2 2 21 11 1 1 11 2 2 Novoaidarivskyi Kyiv U K R A I N E MAP OF DISTRICTS WHERE CHILD CASUALTIES OF MINE/ERW ACCIDENTS HAVE BEEN REPORTED Figure 1 MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 17 Figure 1 illustrates the location and total number of all known child mine/ERW victims since 2014 (both GCA and NGCA). Though most casualties are recorded in the NGCA, because of restricted access, the families of child mine/ERW survivors in this area could not be reached. It is not uncommon, in both the GCA and the NGCA, for accidents to be recorded far from the contact line. This is indicative of the danger posed from ordnance migrat-ing away from the area in which it was intended to be used, either as a result of trophying (children collecting interesting items as trophies including from military training grounds), or possibly due to the illegal proliferation of arms and associated material. Figure 2 illustrates how heavily casualty statistics amongst child mine/ERW victims are weighted towards males. This trend holds true when extending analysis to accident rates amongst adults. The data also illustrate a slight trend towards older, male children (from nine years old upwards) being the most at risk from suffering mine/ERW accidents. 4 3 2 1 01 2 4 9 10 11 12 13 14 15 16 17 N/A Freq uenc y Age Female Male Figure 2Child mine/ERW victims by age and gender The map and charts below are designed to provide a high-level overview of child mine/ERW survivors in terms of number, geography, age and gender according to all available data. MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT18 ANALYSIS BY AGE AND GENDER Of the total sample of child mine/ERW survivors assessed, most are male 82 per cent (14 persons) with 18 per cent (3 persons) female. The youngest survivor identified in the assessment was a four-year-old girl and the oldest, a 16-year-old boy. DRC-DDG conducted one additional house-hold interview with the mother of a boy who was 17 when the mine accident occurred in 2014 and is now an adult. Like the general figures highlighted above, males account for the majority of accidents in the sample of 17 survivors assessed by DRC-DDG. The tendency for males to account for a disproportionate percentage of mine/ERW accidents is also generally consistent throughout mine/ERW contami-nated countries where such data is systematically recorded and disaggregated. Worldwide, males accounted for 84 per cent of mine/ERW casualties in 2017.5 5 Landmine Monitor 2017 Of the total sample, most child mine/ERW survivors were aged between 9 and 13 years of age at the time of accident (all boys). The youngest survivors (two girls), were aged 1 and 3 years old at the time of the accident. As a point of interest, according to DDG internal statistics, during 2014-2018, children account for a significantly lower proportion of accidents (6 per cent) than adults (88 per cent) in Ukraine (for 6 per cent the age is unknown). Globally, in 2017, the casualties ratio was 47 per cent children and 53 per cent adults. There are likely to be a combination of explanations for this divergence in Ukraine from the global pattern. It is well known that the demography of buffer zone communi-ties has shifted in recent years, owing to the displacement of younger more mobile civilians, particularly those with children, meaning that statistically speaking, it is less likely that a child will become a mine/ERW victim than an adult. Other factors such as occupation, location, socio-economic standing, behaviour and attitudes should also be consid-ered. Each could be individually analysed in depth; however, it is beyond the scope of this report to do so. The following section analyses primary data on child mine/ERW victims collected by DRC-DDG. Of a total of 39 cases, DRC-DDG directly contacted 15 households for interviews, covering 17 child mine/ERW survivors in total; 12 families with one child mine/ERW survivor, two families that each had two child mine/ERW survivors and one family, in which a child mine/ERW survivor had turned 18 years old and a younger child had died in the same accident. One households interview was conducted with a family of a child who was injured as a result of small arms fire: the family was identified by the Child Affairs Service and invited for an interview with DRC-DDG. The interview was conducted but the results are not included in the statistics of mine/ERW cases. ANALYSIS CHILD MINE/ERW SURVIVORS Female Male 18% 82% Figure 3 Gender breakdown of assessed mine/ERW survivors Figure 4 Ages of assessed child mine/ERW survivors at the time of the accident 3 2 1 01 3 9 10 11 12 13 14 15 16 17 Freq uenc y Age MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 19 LEGEND Line of Contact UA Control Area of high concern Territory of Ukraine Non-Government Controlled Area (NGCA) 15 km Zone Number of child victims District with child casualitiesmine/ERW accidents Oblast boundary 1 SEA OF AZOV Kostiantynivka Bahmutskuy Bilovodskiy Svativskiy Volnovaskyi Marinskyi Popasnianskyi DONETSK OBLAST LUHANSKOBLAST Nikolskyi StanychnoLuhanskiy 4 3 1 1 1 1 2 2 2 Kyiv U K R A I N E DISTRICTS WITH CHILD CASUALTIES FROM MINE/ERW ACCIDENTS (VISITED BY DRC-DDG) Figure 5 ANALYSIS BY GEOGRAPHY MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT20 Urban Rural 21% 79% Figure 6 Locations of the assessed accidents Figure 7 Type of accident Figure 8 Activity during accident Most of the assessed accidents were registered in rural areas of Donetsk and Luhansk Oblasts. The findings confirmed the perception that rural areas tend to have lower coverage of governmental services such as hospitals, police and social services, meaning that the population residing near the contact line are both at higher risk of suffering mine/ERW accidents and have a lower prospect of receiving timely and high quality needs-based assistance. The majority of casualties (15) resulted from picking up, tampering with, handling or playing with ERW. The children found the ERW or unidentified explosive devices during their free time. At least ten children brought an item home either to play with or to decon-struct or make a memorable object (e.g. an amulet). ANALYSIS BY TYPE OF ITEM AND CAUSE OF ACCIDENT Taken together, the figures above illustrate that the trend, particularly among children, is for accidents to be caused by ERW, rather than landmines. Further-more, accidents are not generally casued by inadvert-ent contact with such devices, but rather by children actively disturbing or otherwise handling ERW. This would indicate that there is a need for more wide-spread risk education campaigns (only 42 per cent of victims had received mine risk education prior to their accident), or that such risk education does not manage to penetrate the consciousnessness of children enough for them to modify their behaviour and/or attitudes towards the risks associated with handling or disturbing ERW. 3Unidentified explosive deviceMine 1ERW 13 15Picking up / tampering with / handling / playing with Travelling 1 Collecting wood 1 3Unidentified explosive deviceMine 1ERW 13 15Picking up / tampering with / handling / playing with Travelling 1 Collecting wood 1 MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 21 Figure 9 Type of injuries ANALYSIS BY TYPE OF INJURY Of all the injuries received by child mine/ERW survivors assessed by DRC-DDG, injuries of upper limbs (65 per cent), lower limbs (53 per cent) and head/neck (53 per cent) prevail. Of the 17 assessed survivors, one person received no physical injuries but (as reported by the mother) psychological trauma. RIGHT SIDE eyesight hearing arm hand/fingers leg18% above knee below knee foot/fingers 12% 6% 24% 29% 18% 18% 6% LEFT SIDE eyesight hearing arm hand/fingers leg24% above knee below knee foot/fingers 12% head/neck 53% chest 41% 6% back 12% buttocks 6% lower limbs 53% upper limbs 65% abdomen 41% 35% 47% 18% 18% 6% MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT22 In terms of the physical impact of the accident, scars (82 per cent), shrapnel in the body (71 per cent) and ampu-tations of fingers (24 per cent) and hands (18 per cent) prevail. All six cases of amputation arising from the acci-dents were accounted for by boys. Examining the trend in types of injuries received by those surveyed, it is clear that several types of specialist medical assistance will be required by the victims, both in the pres-ent and the future. Complications arising from traumatic amputation; loss of mobility, vision and hearing and other physical injuries, particularly embedded shrapnel, all require significant and usually ongoing specialist medical attention. It is a sad fact that Ukraine has not yet suffered its last mine/ERW casualty. There will likely be a steady flow of casualties for years to come as clearance efforts are ongo-ing. Understanding the types of medical assistance most likely required in anticipation of this will help ensure that adequate support is in place. ANALYSIS BY SOCIAL PROFILE AND ECONOMIC IMPACT With regard to the structure of the affected households, 8 of the 15 families are headed by single mothers, and 4 have more than three children under the age of 18. Of the 15 assessed families, in nine households (60 per cent) salary is the main source of income. Eleven house-holds (73 per cent) receive social payments, and for at least six households (40 per cent) this is the main source of income. Of the 14 households who reported their incomes, at least 11 live under the average living wage (UAH 1,800 / US$65) per person, of these 7 are single-headed house-holds and 4 have three or more children. The data suggest that socio-economically, the child mine/ERW victims surveyed were from lower-income families. As mentioned previously, research near the contact line in eastern Ukraine has indicated that those with the means to do so, particularly those from settlements in close proximity to the frontline (i.e. those areas more likely to be more high-ly contaminated by mines/ERW), have tended to move away from the area. Those left behind tend to be the more elderly or have low income who have no choice but to remain in place. It is therefore reasonable to conclude that mines/ERW are affecting those from lower income families to a disproportionate degree to those who are not. When asked whether the family had any changes in income after the accident, five families reported decreased income of whom, three were due to spending related to continued medical care and two resulted from the need to take care of the child rather than working. All families who reported de-creases in income are living under the average living wage. Lesions Partial deafness Blindness in one eye Slight visual impairment One amputated / atrophied hand Amputated fingers Shrapnel in the body Scars 6%6%6% 12%18% 24%71% 82%Figure 10 Physical impact of mine/ERW accident MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 23 Decreased Not changed 36% 64% 6 persons32% 8 persons42% 3 persons16% MRE before accident MRE after accident Did not receive MRE Figure 11 Changes in income after accident Figure 12 Mine risk education for child mine/ERV survivors In most cases, these families [the families of child mine/ERW victims] are marginalized all they need is money Staff member of governmental social service in Donbas When analysing the profile of child mine/ERW victims, it was important to understand whether the victim had been exposed to risk education and when, in relation to their ac-cident (before or after), they had received such education. When asked about mine risk education (MRE) training, eight children had received MRE before the accident, six after the accident, and three had not received any MRE. Two families expressed need for all family members to re-ceive MRE: these were families in which children had already received MRE (one before and one after the accident). The inferences that can be drawn from this sample are that receiving MRE does not make children immune from accidents and that further MRE is needed as a preventive measure. A final but important point to note is the concept of inter-view fatigue among mine/ERW survivors. The more assess-ments and interviews that are conducted by journalists, for example, without any tangible result for the interviewee, the more frustration is created. DRC-DDG encountered this sentiment among a small number of interviewees during the course of the assessment. Some families were exhausted after interacting with journalists follow-ing an accident. There is a high risk to dignity. After my child [a mine survivor] saw another boy mine sur-vivor in the news, he asked me not to put him on television. And I protect him from any interaction with jour-nalists. Mother of mine survivor MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT24 This section seeks to analyse and identify the gaps that remain to addressing mine victim assistance comprehensively in Ukraine. The section is broken down by subject, according to the main pillars of mine victim assistance laid out in the United Nations Policy on Mine Action. The pillar of data collection is not discussed in this section, as it is more relevant to frame this topic within the analysis of stakeholders and service providers, covered in the next section. EMERGENCY AND CONTINUING MEDICAL CARE ACCESS: All the interviewed victims received treatment in govern-mental medical facilities. First aid was provided in local medical facilities, in ambulances and/or by military doctors. Three child mine/ERW survivors assessed by DRC-DDG re-ceived first aid from military doctors. For example, the life of a child was saved because a military doctor was present in the location. In most of the cases that involved severe trauma, the children were transported to oblast-level hos-pitals. Emergency treatment was delivered free of charge in the hospital. In cases when medicines were not available at the hospital, the families were supported by volunteers, local residents, local and international organizations (e.g. Pomozhem (a local NGO) and the ICRC) to pay for medical bills. Of the 17 child mine/ERW survivors assessed, 12 persons required continuing medical care. Medical care was mainly received at the Okhmatdet National Childrens Specialized Hospital, in Dnipro, Zaporizhzhia, Kharkiv, Volnovakha, Lysychansk and, in one case, in Luhansk (NGCA). In at least two cases, medical errors were made and, as a result, the children require regular medical treatment and support at oblast-level hospitals. NEEDS: All the children who require continued medical care are in need of regular examinations of their conditions. Their oth-er ongoing needs include pain management (some children suffer from pain and do not receive any treatment), plastic surgery and surgery in advance of prosthetics. BARRIERS: Some families have to travel to the hospitals where they underwent treatment on a regular basis because they are being refused at local level. For example, one mother stated that: The doctor refused to do bandaging for us, but she could not explain why. Often, the families of child mine/ERW survivors did not receive complete information about the health conditions of their children. For example, in one case a mother found out in secret about the severe health conditions of her child from medical staff: They hid [from me] that there was shrapnel in the childs body; the nurse said that they [the doctors] were hiding it from me. The mother could not explain why. ANALYSIS: NEEDS AND BARRIERS TO ASSISTANCE FOR CHILD MINE/ERW SURVIVORS 1SurgeryShrapnel removal 4 Regular examinations 155Plastic surgery Pain management 3 Figure 13 Medical care needs of child mine/ERW survivors MINE VICTIM ASSISTANCE NEEDS ASSESSMENT REPORT 25 Caregivers need to take initiative to ensure regular medical examinations for children. However often parents are not aware or informed by medical staff about the importance

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