Social Mobilisation and Communication for Polio Eradication: Documentation in Nigeria, India, and Pakistan

This 67-page documentation study evaluates progress in addressing social mobilisation and communication needs related to the global eradication of Polio. The research was carried out at the request of the Polio Eradication Initiative (PEI), which was launched in 1988 under the aegis of the World Health Assembly (WHA). In response to apparent obstacles to interruption of transmission in the 3 remaining polio-endemic countries (Nigeria, India and Pakistan), PEI's Technical Consultative Group (TCG) met in April 2002 to raise questions about the nature, structure, conduct, and impact of PEI's social mobilisation/communication (SM/C) activities.

This 3-country documentation study, which is based on qualitative field research conducted by an independent consultant under joint contract to WHO and UNICEF, is an effort to help answer some of those questions.

Excerpts from the Executive Summary follow:

Progress has been made. The principles of social mobilisation and communication as necessary components in the Polio eradication programmes in all three study countries are well-acknowledged. Social mobilisation/communication infrastructure and practice have been established and developed.

Mass media and mass distribution Information, Education & Communication (IEC) materials have been well established in all three study countries. This includes:

• Involvement of high-profile celebrities (India, Pakistan);
• Production of high quality mass media TV and radio spots (Nigeria, India, Pakistan);
• Production and improved distribution of high-quality print materials (India, Pakistan);
• Mobilisation of resources from international and local private sector partners (Pakistan);
• The expanded use of regional/local broadcast channels and stations;
• An increased focus on evaluating media and products.

The majority of social mobilisation budgets is allocated to mass communication efforts. General awareness levels with regard to Polio and the Polio campaign are very high in all countries (at 90-100% in most areas), and have been adequate for 12-18 months. Mass communication has clearly achieved its principal goal...

Government ownership of the Polio eradication programme remains strong at high levels. However there has been a lack of emphasis in social mobilisation/communication on advocacy aimed at local level administrative institutions (in Nigeria, the Local Government Authority (LGA), in India and Pakistan, the District)...

Coordination between international agencies within the Polio partnership has improved in some cases dramatically since 2001. However, there are remaining issues:

• A persistent and potentially damaging ambiguity in the political and strategic prioritisation of PEI and EPI [Extended Programme on Immunisation];
• Limited or non-existent joint technical and social microplanning, monitoring and evaluation.

The programme remains fundamentally divided into 'social' and 'technical' sides. Complementarity between the two programme components has by no means been fully exploited. Poor data circulation, management and analysis can lead to social mobilisation and communication activities that are not directly field data-led, resulting in activities whose relation (or contribution) to the overall PEI goal of successful vaccine delivery cannot be directly attributed and cannot consequently be properly evaluated.

The current epidemiological profile of Polio is characterised by diverse reservoir-based patterns of relatively small-scale, local circulation. While SIA [supplemental immunisation activity] coverage averages are increasing in most cases (and in many instances reaching 95+%) the epidemiological data show a persistent coverage 'gap' of up to 15% (and in some instances more). It is this gap that supports continuing WPV transmission and on which social mobilisation and communication should concentrate:

• The primary issue for the eradication campaign in early 2003 is small remaining groups of 'missed children';
• Social mobilisation and communication strategy should shift emphasis from the existing (and completed) extensive, mass awareness approach, to a new intensive approach addressing the specific conditions of the local groups in which children continue to be missed.

The prevalent explanation for remaining missed children is 'resistance' attributed to whole communities, groups and individual households. Poor OPV [Oral Polio Vaccine] coverage is attributed to the refusal of householders to accept vaccine, and that refusal is attributed, fundamentally, to religious belief, 'fatigue', and/or ignorance. The communication strategy that flows from this centres on repetitive 'explanation' and instruction. There is increasingly limited evidence that this is an effective approach. Analysis of the dynamics of SIAs and OPV delivery show that:

• The use of 'resistance' to explain poor programme performance is empirically unsound;
• Poor coverage should be understood as the result of serious, valid and rational questions about OPV, the continuous programme SIAs (in the context of poor or non-existent wider public services), concerns regarding efficacy and safety, and of more practical considerations such as the whereabouts of children when vaccinators arrive, children with other health problems and so on.
• Social mobilisation and communication strategies should develop locally-articulated strategies that respond to local questions and concerns, shifting from an instructive to a negotiating approach;
• In support of this strategic shift, the need for more articulate local face-to-face OPV negotiation (and delivery) centralises the role of the vaccinator.

Vaccinator teams in all three study countries are an under-developed and under-used resource. Poor retention rates have created disincentives within the programme to concentrate on building vaccinator capacity. Specifically, vaccinators have been constituted as a technical resource and have received little or no training in the interpersonal communication (IPC) skills that are vital to the quality of their OPV delivery performance.

Although mass media communication has increasingly benefited from evaluation, more localised (IPC) social mobilisation activities - principally contact meetings with local civil social and public sector 'influencers' - have not. Clear strategies and PEI-related objectives should be set for all contact social mobilisation activities, and concrete indicators established by which the contribution of these activities to the overall programme objective can be evaluated. At a broader level, logical framework planning and design is needed for all social mobilisation and communication materials and activities, in order to rationalise their production and application under the primary objective of Polio eradication.

Recommendations

In the main narrative report, recommendations specific to each of the three study countries are made. Focusing on the thematic continuities in social mobilisation and communication work going on across the PEI programmes, however, the following general recommendations are offered:

• Ensure that all social mobilisation/communication activities are driven by epidemiological data (focus SM/C on demonstrably vulnerable groups);
• Integrate social mobilisation/communication and technical microplanning, monitoring and data analysis procedures;
• Re-assess 'resistance' and develop 'negotiation' strategies (focusing on the role of the vaccinator) to address locally researched OPV questions and concerns;
• Adopt vaccinators as a key communication resource, and vaccinator recruitment and training process as a major operational responsibility for social mobilisation/communication;
• Rationalise mass media work and shift emphasis of funding to localised (District/LGA) social mobilisation and communication activities;
• Inventory all existing SM/C materials and approaches to determine their direct PEI-related objectives and establish a logical framework process for developing new materials and approaches. Document a systematic approach to local advocacy and media management.

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