Achieving Polio Eradication: A Review of Health Communication Evidence and Lessons Learned in India and Pakistan

"There is no vaccine against resistance or refusals that are rooted in social-cultural, religious and political contexts. No supply chain can overcome issues of gender-based decision-making in households. Medical approaches alone can not address certain community concerns...These challenges demand effective communication action..."

This report explores the role that communication interventions have played in the effort to eradicate polio through the Global Polio Eradication Initiative (PEI). The review examines polio communication efforts in India and Pakistan between the years 2000 and 2007, showing how epidemiological, social, and behavioural data guide communication strategies that have contributed to increased levels of polio immunity, particularly among underserved and hard-to-reach populations. It illustrates how evidence-based and planned communication strategies - such as sustained media campaigns, intensive community and social mobilisation, interpersonal communication, and political and national advocacy - have contributed to reducing polio incidence in these countries.

The introductory section of the report provides background, explaining that the PEI is organised by the World Health Organization (WHO), Rotary International, the United States (US) Centers for Disease Control and Prevention (CDC), and the United Nations Children's Fund (UNICEF). Other leading partners include the United States Agency for International Development (USAID), the Bill & Melinda Gates Foundation, governments of polio-affected countries, donor agencies, and non-governmental and private sector organisations. Primarily through mass vaccination campaigns, the Initiative cut the number of polio cases from about 350,000 in 1988 to 1,643 by January 2009. However, polio is still endemic in Afghanistan, India, Nigeria, and Pakistan. Reaching the hardest-to-reach, the economically poorest, the most marginalised, and those without access to health services remains a critical challenge in all 4 countries.

To understand how communication has been brought to bear on this challenge, the authors conducted a review of primary and secondary data sources, including research, evaluation, and technical reports, as well as policy, theme, and working papers, that document communication efforts for polio eradication in India and Pakistan. This review highlighted several communication challenges, such as the difficulty of reaching underserved populations where immunity is too low to stop circulation of wild polio virus. Recognition of this reality represented a turning point in the PEI's strategy, because "information alone is not sufficient to encourage behaviour and social change in these populations that would lead to acceptance of OPV", or oral polio vaccine. Therefore, the twofold communication challenge has been to: (i) engage and convince caregivers in hard-to-reach areas of the benefits of vaccinating their children, and (ii) ensure that caregivers whose children have received OPV are motivated to continue vaccinating their children.

In short, then, "While widespread mass media campaigns continue to ensure national visibility and public awareness of the Initiative, augmentation of interpersonal communication and social mobilization interventions have become crucial to reach unreached populations." In India, for example, a social mobilisation network involved coordinators working at different levels: the sub-district, block (covering about 100 villages), and community (village) levels. Mobilisation coordinators at each level teamed up with vaccination teams for routine follow-up of families. Activities included house-to-house visits as well as systematic and sustained mobilisation of community and religious leaders and influencers (e.g. local doctors, Imams).

To illustrate how these activities have contributed to eradication efforts, the authors cite several evaluation reports. In general, the conclusion is that, in both India and Pakistan, "Communities where social mobilization activities are conducted are consistently less likely to refuse OPV, more likely to attend booths and more likely to report positive attitudes towards OPV and higher perception of polio risk, compared with families in communities without these activities, hence contributing to lower incidence." The use of programme and research data such as that cited here enabled Pakistan's PEI to revise its communication strategy to focus on messages for specific audiences and adapt behaviour-change goals towards improving OPV acceptance. For instance, based on data showing that female caregivers play a primary role in the decision-making regarding immunisation, the communication strategy refocused on reaching women: Trained female health workers spearheaded intensified efforts to communicate directly with female caregivers or indirectly through females in the community, with messages designed to shape attitudes towards OPV and perceptions of risk of polio.

As reported here, the challenge of reaching underserved and hard-to-reach populations in India led to efforts to engage influential Muslim training institutions and religious and community leaders in building public confidence and credibility in the PEI. The fact that these personnel can be strong allies when properly engaged is supported by data cited here, such as findings from 2007 showing that, after involving religious leaders in polio eradication activities, coverage of children in families refusing due to religious reasons increased from 13% in August to 17% in October, and coverage of families refusing due to misconceptions increased from 37% to 50% in the same period.

The review also highlights the role of mass and folk media and advocacy in increasing awareness and booth attendance. For example, nearly 92% of 9,370 respondents to a 2003 evaluation of large-scale mass media campaigns involving movie and cricket stars and political figures in India cited television and radio spots as "very influential" or "influential" in their decision to take children to vaccination booths. Entry and exit polls following exposure to messages on local media among 2,552 randomly selected respondents showed a 60% increase in awareness of the next National Immunization Day (NID)'s date and a 20% increased intention to get their children immunised at the booth. Advocacy efforts have focused on mobilising professional associations and enlisting their support for polio eradication activities, particularly during NIDs.

The review concludes with observations about the added valued of communication strategies in polio eradication efforts and implications for global and local public health communication interventions. In short, "Strategic and synergistic communication efforts that integrate social mobilization, interpersonal communication, gender- and culturally-sensitive interventions, mass/folk media and political advocacy have contributed to the Initiative's progress and to access unreached populations in challenging socio-economic environments. Principles underpinning communication strategies in India and Pakistan include: i) use of epidemiological, social and behavioural data to assess social/individual constraints, such as knowledge gaps and resistance, to develop effective interventions to reach underserved groups; (ii) development of innovative and intensive interpersonal communication/social mobilization strategies; and (iii) engagement of community and religious leaders."