National Emergency Action Plan 2022: Polio Eradication Initiative Afghanistan

"Despite multiple challenges faced by the programme in 2021, polio communication interventions successfully promoted and maintained general vaccine acceptance across the country..."

2021 was quite a challenging year for Afghanistan's polio programme, leaving a significant number of children unreached. The security situation was varied, resulting from full-scale armed conflicts across the country that lasted till the middle of August 2021, followed by takeover by the Islamic Emirate of Afghanistan. In this context, the ongoing inability to implement house-to-house (H2H) vaccination campaigns throughout the country since 2018 has led to continued drop in the immunity against polio. Afghanistan also saw a political transition around mid-2021. Keeping in view the polio epidemiology (slightly improved during 2021) and various challenges, the National Emergency Action Plan (NEAP) for polio eradication was updated for 2022 using a consultative approach at the national and sub-national levels. The summary below highlights central communication-related components of the NEAP report.

The NEAP 2022 has several objectives, including, for example, these communication-related ones:

• Ensure safety and protection of polio health workers at the forefront from all forms of violence during polio eradication activities. (In March 2021, three female polio vaccination workers were gunned down in Jalalabad and Surkhrod districts of Nangarhar province while conducting H2H vaccination; in the June campaign, 10 polio workers were attacked in Nangarhar. These incidents seriously dented the programme's efforts to improve women participation in campaigns: The percentage of women vaccinators reduced in Jalalabad from 72% in March 2021 to zero in June 2021.)
• Resume and maintain house-to-house vaccination campaigns across the country to build and sustain population immunity against wild polioviruses (WPVs) or circulating vaccine derived poliovirus (CVDP). (That said, reaching newborns is an operational and communication challenge in light of factors such as the cultural practice of keeping newborns inside the house for 40 days from birth and the absence of women vaccinators. While female participation among polio workers initially improved in high-risk areas of South and East Regions, it deteriorated from mid-2021 onward. Although the campaign modality impacted women's participation, 998 women social mobilisers (24% of the total number) were involved as campaign-based social mobilisers for both mosque to mosque (M2M) and H2H.)
• Engage community members and leaders to increase acceptance and demand for vaccination by addressing vaccine refusals through effective and locally appropriate communication/social mobilisation strategies. (As reported here, throughout 2021, the programme continued its efforts to address vaccine acceptance issues through a wide variety of community engagement and social mobilisation activities, such as engagement of religious leaders, grandmothers, and local authorities. Region-specific approaches were adopted, the Immunization and Communication Network (ICN) network was streamlined and tailored to local needs, and partnerships with local communities, including working with grandmothers, husbands, religious leaders, media engagement, and authorities, were strengthened.)
• Promote gender equality at programme planning and implementation level, appropriate to Afghanistan context. (Examples include: incorporation gender-related analysis in all programme components, with focus on high-risk communities/localities; including clear parameters in the programme's human resources policy at all levels to ensure gender equality and ongoing supportive supervision of female workers/staff; enhancing women's inclusion in supervisory and mid-managerial positions, as feasible, to support further increase in women’s participation as polio health workers; and ensuring protection of the beneficiary populations and of the personnel working for polio eradication from sexual exploitation, abuse, and harassment.)
• Improve the availability of social data to track rumours and monitor community attitudes towards polio vaccine. (The United Nations Children's Fund (UNICEF), a partner in the Global Polio Eradication Initiative (GPEI), introduced the use of U-report and Viamo remote (telephone-based) surveys to understand community perception, awareness, and acceptance of polio vaccinations during November and December campaigns in 2021. Data showed that the majority of respondents implied they would vaccinate their children during the campaign. However, not all responders eventually presented children to be vaccinated. The most common reasons for not vaccinating child during the campaign included husband not being at home and mother being unable to walk to the mosque. The programme has used this data to inform communication and community engagement gaps and appropriate deployment of frontline social mobilisers, especially for surveys conducted pre-campaign.)

Going forward, the programme will leverage strategic communication interventions for awareness and commitment from all stakeholders at national and subnational level, including from communities, for a polio-free Afghanistan. This approach will involve creating awareness, improving communities' knowledge on vaccine importance, and changing people's perceptions towards the polio vaccine. Successful implementation of these interventions will require in-depth understanding of the community issues and the environment in which the polio programme operates. The programme seeks to:

• Increase engagement by focusing on community consultation and strengthen community participation to improve vaccine acceptance, especially in cross-border communities;
• Improve evidence generation activities by collecting real-time data on vaccination perception, refusal, and rumour tracking; and
• Build the capacity of community groups for engagement and social mobilisation during the campaign.

Specifically, the programme will adapt community engagement and social mobilisation work around 4 key pillars, with an emphasis on polio high-risk districts and areas previously inaccessible to the programme:

1. Risk communication and community engagement (RCCE): The programme will engage stakeholders, partners, and communities in a transparent and 2-way manner to increase awareness about the inherent risks of poliovirus outbreaks, especially in the context of multiple humanitarian crises in Afghanistan. Sample activity: Improve interpersonal skills of polio health workers at the forefront (e.g., ICN, female vaccinators) to effectively communicate the risks of poliovirus transmission.
2. Social norms and social cohesion: Actions to be taken to address practices that impede polio vaccinations include: analysing religious perspectives; conducting an appreciative inquiry approach with stakeholders (religious and community leaders); and carrying out norms analysis to understand gender dynamics in communities and households, positive practices, and entry points for community awareness and engagement for polio vaccinations.
3. Social mobilisation for supplementary immunisation activities (SIAs): The programme will bring together stakeholders and communities to raise awareness on risks of poliovirus outbreaks, potential misinformation, and polio vaccination activities. Various channels, including mass media, social media, and print and interpersonal communication will be used. Social mobilisation interventions will be aligned with SIA modality (H2H or M2M); for example, for M2M campaigns, religious leaders will be rallied to facilitate mobilisation by announcing campaigns at the mosque and communities. Campaign-based social mobilisers will conduct street announcements (e.g., using megaphones) to bring more caregivers to the vaccination sites. Pre-campaign media announcements will also be used to raise awareness on the importance of polio vaccinations.
4. Behaviour monitoring and accountability to affected populations (AAP): Specific approaches will include:
   • Establishing information sharing and communication channels (daily radio shows, grandmother meetings, and madrassa discussions) so that communities understand the importance of polio vaccinations and make informed decisions regarding vaccinations.
   • Using hotlines and other tools (Viamo surveys and U-reports) to capture community voices and provide feedback about polio vaccination services.
   • Engaging duty bearers at all levels by creating awareness about their roles and responsibility to communities about polio vaccinations.
   • Regular monitoring of community behaviour through listening and analysis of community conversations.

The programme will leverage the following thematic areas to expand the depth and reach of polio social mobilisation and community engagement activities, improving community participation in eradication initiatives. In brief:

• Coordination and expansion of partnerships, including with communities - e.g., by activating partnerships with universities to create awareness about polio and campaigns and conduct independent surveys/in-depth studies to understand the reasons for missing vaccinations, along with updating training tools and information to be shared with partner universities and non-governmental organisations (NGOs).
• Gender - Although the programme has involved women and girls at all levels, the security situation and social barriers have limited their role. The programme will focus on activities to mainstream gender approaches into programming and decision making, such as strengthening gender training on gender-related barriers and gender activities among all the partners.
• Innovation - In consultation with community groups and polio health workers at the forefront (i.e., female vaccinators and ICN), and based upon an understanding of the local norms, community initiatives will be supported to create innovative interventions. The initiatives aim to address the lack of motivation and polio message fatigue, such as by promoting UNICEF's Aisha character as an example for fighting poliovirus in Afghanistan.
• Communication and advocacy strategies - The programme's communication team will work to incorporate voices of all stakeholders for a comprehensive and fit-for-purpose strategies. One example includes developing a plan of action for the introduction of novel oral polio vaccine type 2 (nOPV2), which will require tailored communication preparedness measures. Specific types of communication and advocacy plans include:
  • Mass media engagement - Examples of plans include: mapping and developing media partnerships, including in areas previously not accessible to maintain consistent awareness and community trust; reviewing the media engagement plan to ensure timely broadcast placement of polio communication products on all media buy channels; intensifying media roundtable discussions, engaging key influencers, including religious leaders, community leaders, and medical experts in these discussions; ensuring campaign monitoring systems and media impact assessments are implemented; and producing high-quality multimedia materials to influence behaviour change towards vaccine uptake.
  • Digital media engagement and other innovations - December 2021 U-Report survey data showed that 31% of Afghan communities learned about the polio campaign through social media, indicating that social media engagement is playing a critical role in creating awareness and disseminating key polio messages. One example of a digital media engagement action: using WhatsApp groups within the social mobilisation network to disseminate messages and to track rumours/misinformation.
  • Crisis communication - Crisis communication training was conducted at national and regional levels in 2021. In 2022, support will be provided to all Emergency Operation Centres (EOCs) to ensure a well-laid-out crisis communication response protocol is developed, and mapping for potential crisis scenarios will be done as part of the preparedness for the introduction of nOPV2 vaccine.
  • Partnerships and advocacy interventions - For example, new partnerships with organisations such as sports associations and other influential organisations will be established to play a critical role in vaccine acceptance.
  • Cross-border communication interventions - Cross-border communication initiatives with Pakistan need strengthening to address high-risk mobile population movement between the two countries. Activities will include: development of synchronised communication materials for the border crossing points; engaging media and known influencers with reach along the borders to create polio awareness and to influence vaccine acceptance; and initiating social listening approaches along the border.
  • Islamic Advisory Group (IAG) initiatives - Sample intervention planned: training final-year students of medicine and Shariah in select universities, as well as senior madrassa students, on the importance of polio vaccination, routine immunisations, and child health from the religious and health perspectives using the curriculum developed by the IAG in collaboration with Al-Azhar University, the World Health Organization (WHO), and UNICEF.