Fatigue and Fear with Shifting Polio Eradication Strategies in India: A Study of Social Resistance to Vaccination

"Given that polio eradication necessitates almost complete vaccination coverage, unclear communication about vaccination policy seems to have been problematic..."

This qualitative study contextualises some sources of fear and "resistance" to the Global Polio Eradication Initiative (GPEI) as it was carried out in India during the summer months of 2009 to provide insight for future eradication endeavours. The study focused initially on resistance to the vaccine regarding rumours of sterilisation amongst the Muslim community; when it became apparent that resistance had spread into the non-Muslim community, the study was broadened to identify knowledge and opinions about the eradication strategy amongst the general public.

This research took place in the city of Aligarh in Uttar Pradesh, India. Aligarh District was classified as a "high-risk" district for the spread of polio by the GPEI and was the source of the majority of India's polio cases in 2003. The researcher used the method of participant observation to collect data both at clinics run by the GPEI and the door-to-door vaccination programme. During the door-to-door programme, the researcher was embedded with polio vaccination teams as they attempted vaccinating families, described as "resistant" families, who had actively refused in the past to accept vaccination. Twenty-seven formal interviews were conducted with both grassroots and administrative stakeholders in the polio eradication programme. The in-depth structured interviews were conducted with health promoters called Community Mobilizing Coordinators (CMCs) (5), polio booth-workers (5), clinicians who worked in underserved areas (4), medical interns (5), community physicians (5), and administrators with the GPEI. Eighty formal, semi-structured interviews were also conducted amongst families with children who interacted with the polio eradication programme in major parts of Aligarh.

In summary, the research found that there is:

• Fatigue and confusion from programme intensification: "During the course of the study, families in Aligarh showed fatigue from vaccinating their children monthly because they did not understand the need to do so. Though most respondents supported the eradication program and vaccinated their children, many did not seem informed why the program had intensified the frequency of vaccination. Families described that when they asked the door-to-door vaccination teams why they visited them so often, they were usually not given an adequate response."
• Lack of information about the strategy to eradicate the P1 strain of the virus through the monovalent oral polio vaccine (mOPV1): "Families were not usually informed of differences between the strains: P1 and P3; and when they saw or heard of polio cases occurring, usually P3 at the time, many came to doubt the efficacy of the monthly administered vaccine, which only targeted P1....The lack of awareness about the vaccine was often reinforced by the vaccination teams."
• Fear from adverse events proximate to vaccination: "Throughout Aligarh, there were rumours that when some families vaccinated their children against polio, the next day the children contracted a fever, became afflicted with polio, or even died....The fact that vaccinators told them the vaccine wouldn't cause any harm before administering what was a lethal vaccine in the rumour caused families to further distrust the program."
• Distrust of the vaccination teams: "Many people, especially from the upper classes, felt that they would not only put their children at risk of adverse events from the broken cold-chain, but possibly other diseases as the teams vaccinated multiple children with the same dropper. Many of these respondents were not afraid of the vaccine per se and said that they would gladly go to a physician or clinic for the same vaccination."
• Failure on the part of vaccination teams to share information with families regarding either the intensification of the vaccine programme, use of mOPV1 versus the trivalent OPV, or risks associated with vaccination: "One of the local community physicians who worked regularly with the polio eradication initiative explained that because people were uneducated, only minor risks associated with vaccination were shared with patients. Major ones like VAPP [Vaccine-Associated Paralytic Polio] were ignored because of the risk of rumours."

The discussion section of the paper stresses that increased transparency and an adverse-effects compensation programme may need to be considered to build more trust with the public in future programmes. "Though the policies of not disclosing the risks associated with OPV vaccination or explaining the monovalent strategy were initially done to avoid confusion and achieve high levels of vaccination, if trust with the public was affected, it would have been important to increase policy transparency and improve information, education, and communication (IEC) activities." For example, it is noted that the United Nations Children's Fund (UNICEF)'s Underserved Strategy and Social Mobilization Network (SMNet), whom this study was conducted with, had improved communication between the GPEI and local communities by holding educational skits and plays about polio and recruiting grassroots stakeholders such as religious clerics to advocate for vaccination. Another insight to emerge relates to community participation: "If the public had been involved from the beginning, it is possible that some of the resistance may have been reduced. Families were especially frustrated with the top-down nature of the polio program since it was not their principle priority. With open sewers, diarrheal illnesses, and unpaved roads: their priority was development."

In conclusion: "Though India has almost eradiated polio, the lessons learned here about the nature of social resistance should be considered to build and keep trust with the public in other polio-endemic regions and future eradication efforts."