The CORE Group Polio Project's Community Volunteers and Polio Eradication in Ethiopia: Self-Reports of Their Activities, Knowledge, and Contributions

"Moving forward, community-based volunteers will be a valuable resource for addressing global, national, and local health priorities in resource-constrained settings."

In support of the Global Polio Eradication Initiative (GPEI), more than 10 million community-based health volunteers have participated in supplemental immunisation activities (SIAs) and administered oral polio vaccine (OPV). This article describes the development, knowledge, and practices of a specialised type of community volunteers (CVs), whom the CORE Group Polio Project (CGPP) has trained and deployed in sparsely populated regions of Ethiopia inhabited by pastoralist and semi-pastoralist populations and in border areas at high risk for transmission of poliovirus from neighbouring countries. This article, which is part of a series of articles detailing the work of the United States Agency for International Development (USAID)-funded CGPP (accessible through Related Summaries, below), also reports the results of a 2016 survey of CVs.

The CGPP CVs are selected jointly by the local community, local government officials, and local health facility staff. They work closely with the health extension worker (HEW) in their area and are responsible for 50-100 households in all 85 hard-to-reach pastoralist, semi-pastoralist, and international border areas of CGPP implementation districts of 5 regions of the country. Training on immunisation, vaccine-preventable diseases (VPDs), and community-based surveillance is provided by HEWS and by field officers of non-governmental organisations (NGOs) that are CGPP project implementation partners. More than 12,000 CVs have been trained and have reached 6 million people. They make routine home visits to: (i) provide education on VPDs, (ii) promote healthy behaviours, (iii) inform parents on how to access immunisation services, and (iv) report cases of acute flaccid paralysis (AFP), neonatal tetanus, and measles, as well as births.

Other elements of the work:

• Supportive supervision is a facilitative approach to supervision that promotes mentorship, joint problem-solving, and communication between supervisors and supervisees.
• The CGPP CVs attend regular monthly meetings organsed at the health post to which they are attached (and where 2 HEWs are based). In addition, CVs meet periodically with their supervising HEW, and together they exchange ideas and conduct house-to-house visits.
• "CVs are motivated by feelings of responsibility, trust, acceptance, and recognition by their communities to serve and promote immunization and health. Community volunteers are not paid but receive small non-financial incentives to motivate them. Together, the community, the CGPP secretariat, and the NGO partners provide a certificate of recognition for CVs, and the best performing CVs receive an award such as a mobile phone or radio..."

The article also examines the introduction of Health Development Army (HDA) volunteers in 2012, looking at differences between CGPP CVs and HDA volunteers. For example, HDA is led by a command post established at each level of the government's administrative structure: region, zone, district, and kebele. In contrast to CGPP CVs, who are both men and women, all HDA volunteers are women.

Between 2012 and 2017, the CGPP CVs identified and referred 306,432 women in need of tetanus immunisation, 181,192 newborns in need of immunisation, and 71,904 other children younger than 1 year of age who had fallen behind on their immunisation schedule. In addition to their achievements in expanding polio vaccine coverage and caregiver knowledge about polio, which are documented elsewhere in this series, the CGPP CVs during this 5-year period doubled the percentage of fully immunised children (from 25% to 44% according to data recorded on immunisation cards), increased the detection rate of non-polio acute flaccid paralysis (AFP) cases from 2.2 to 2.8 per 100,000 children younger than 15 years per year (compared with the national average of 2.5), and maintained an adequacy of stool samples from children with AFP at 87-92%.

The 2016 survey of 675 CVs demonstrated, for example, that all respondents (94.4%) spontaneously knew that polio can be prevented by vaccination, though knowledge about VPDs is described here as sub-optimal. 84.1% had conducted home visits in the previous month, and 98.2% reported that their work had led to improvements in the community (e.g., 79.0%) stated that their work had led to improvements in immunisation services). Perhaps of concern is that 19.3% of CVs reported they did not receive training before deployment, and virtually all the respondents (94.9% or more) indicated they would like more support such as more collaboration from community members, more training, information sharing, and supervision support from the HEWs. The CVs have a registration book of their activities; however, illiteracy remains a barrier to documentation in some remote pastoralist areas. Illiterate CVs report orally to their supervising HEW, who then writes the information on the monthly report form. Future studies could examine the utility of this process.

In conclusion: "Considering the situation of geographically inaccessible and hard-to-reach areas and the nomadic lifestyle of the population, the CGPP CVs have played an important role in promoting polio immunization and other basic health services." They have also contributed to the surveillance of VPDs and to increasing mothers' knowledge about basic maternal and child health. "This strong performance of the CGPP CVs reflects a dedicated commitment from partners, including the local, national, and international NGOs who work with the CGPP, the government, and the polio eradication program in Ethiopia."