The Polio Communication Network Contribution to the Polio Outbreak Response in Ethiopia's Somali Region, 2013-2015

"The PCN experience in the Somali Region, one of Ethiopia's lowest-performing regions for health indicators, provides important communication lessons for the long term relevant to polio eradication and other public health programs."

This article explores the Polio Communication Network's (PCN) contribution to the polio outbreak response in the Somali Region of Ethiopia from 2013 to 2015. The aim of this network of partnerships and technical assistance is to increase positive polio knowledge and behavioural outcomes in communities by building communication capacity and commitment at local levels, engaging specialised partnerships for social mobilisation (such as local, influential leaders and community groups), and using data for action. In brief, the authors argue that PCN's context-sensitive approaches made significant gains in reaching traditionally missed, hard-to-reach, pastoral communities with polio information, improved communication capacity, and expertise, and contributed to the successful outbreak closure.

As detailed here, a study of the behavioural determinants for immunisation service utilisation in Ethiopia in 2012 showed that communities often lack knowledge about the time, place, and importance of completing routine immunisation. Other barriers include weak health worker interpersonal communication during immunisation sessions, far distances to the immunisation site, fear of vaccine side effects and reactions, inconvenient timing of sessions, and caregiver competing priorities. Perhaps for some of these reasons, in May 2013, a case of wild poliovirus (WPV) was confirmed in Somalia. The poliovirus spread quickly in Somalia, Kenya, and Ethiopia, resulting in a WPV outbreak in the Horn of Africa (HOA) region, totaling 223 cases in 2013 and 2014. Between August 2013 and January 2014, a total of 10 WPV type 1 cases were confirmed in Ethiopia. All cases were confined to the Doolo zone of the Somali Region, a region with low routine immunisation coverage where nearly 90% of the population lives a pastoralist lifestyle. The Federal Democratic Republic of Ethiopia Ministry of Health (FMOH) with support from UNICEF and the WHO responded swiftly; 15 polio supplementary immunisation activities (SIAs) were conducted between June 2013 to June 2015. The last WPV case in Ethiopia reported date of onset of paralysis on January 5 2014. In June 2015, the outbreak was declared closed.

The FMOH led communication efforts building on recommendations made by Global Polio Eradication Initiative (GPEI) experts to implement rigorous, evidence-based strategies. The UNICEF communication for development (C4D) approach was applied, and formal scale-up of locally appropriate communication technical assistance and partnerships was made through the newly established PCN. The PCN strategies and innovations are described in detail in the paper. They include the establishment of a communication network of experts, development of partnerships with locally trusted and influential groups, and capacity building of local structures. The PCN deployed in the Somali Region works alongside regional and zonal health bureaus and offices and includes one regional communication coordinator, nine zonal communication coordinators (ZCCs), a partnership with the Islamic Affairs Supreme Council (IASC), and formal collaboration with female volunteers and local clan and kebele leaders. As the majority of the PCN is deployed in the Somali Region, known for its strong tradition of oral and interpersonal communication for information exchange, the PCN was designed to meet local communication needs with local solutions.

For example, standard messages on polio and child survival were developed and reinforced by religious teachings from the Quran. Cascaded trainings were conducted on polio programme interventions and messages. Dissemination of messages was done through masjids (mosques), Quranic schools, adult learning and religious teaching schools, community conversation sessions, and special lectures or sessions known as "Muhadaras", which were designed to reach women as key decision makers in the vaccination process. IASC representatives participated in the planning, implementation, and evaluation of the SIAs and developed and utilised SIA monitoring formats to report numbers of missed children, to report identified and resolved cases of refusals, and to report mobilisation activities conducted including audiences or individuals reached. The PCN, local teams, and partners recognised the value of intensified involvement of local leaders in microplanning to facilitate ownership, local innovation, and commitment. Furthermore, the PCN was tasked to support engagement of social mobilisation committees (SMCs) by monitoring their functionality, revitalising nonfunctional SMCs, or supporting establishment of new SMCs where none existed. SMCs were supported with training and capacity building, and SMC engagement in health and other topics was monitored.

Results of the research show PCN contribution through sustained high levels of community awareness of polio rounds and low rates of noncompliance with polio vaccination in line with the national indicator (< 1%). The results can be summarised into three categories: contribution to increased awareness; addressed resistance; and an established base of knowledge, human resource capacity, and technical expertise for improved child health.

For example, religious leaders in the Doolo zone were the leading source of information in round 11 of the SIAs (35%), which reflects the first and most intensive round of engagement with the IASC through the Programme Cooperation Agreement in the region. In the Somali Region, between August and December 2014, more than 1.4 million people (39% female), were reached with polio, child, family health, and survival messages, aligned with Quranic teachings according to the monthly IASC monitoring reports. The messages covered polio, routine immunisation, tetanus toxoid vaccination, antenatal care, hygiene, and breastfeeding and were printed on 11,581 brochures together with 1,200 polio posters and distributed to IASC members. In all, 1,480 sheikhs, imams, and Quranic schoolteachers were trained on the polio and child survival interventions, on the dissemination of key messages, and on SIA monitoring. Through masjids, 800,650 people were reached, 28% of whom were female. (A national study reported that 85% of immunisation decision-making power in the Somali Region belonged to women, so this is an important focus of the PCN.) Overall, 601,201 individuals were reached through Quranic schools; 28% were female. Through 138 community conversation sessions, more than 5,070 individuals were reached; 60% were female. One hundred thirty-five Muhadaras with an emphasis on reaching women were conducted, and a reported 17,000 individuals were reached, of whom 41% were female.

Addressing noncompliance and preempting potential noncompliance was a priority for the PCN. PCN tracking, reporting, and resolution of resistant cases allowed teams to take stock of any potentially increasing trends of resistance and address the problem strategically. Furthermore, trainings and role-plays on addressing resistance effectively were an integral part of PCN capacity-building efforts. The collaboration with the IASC was built on GPEI experience (in polio-endemic countries with massive vaccine resistance, at times linked erroneously with religion or politics) to focus on a broad set of mutually developed messages (not limited to polio) and was supported by Quranic teachings. This strategy was decided early on so that the community could reap broad health education benefits from the collaboration (beyond polio) and that they would have confidence in the messages coming from trusted religious leaders, backed by religious teachings. These efforts were deliberate strategies, aimed to thwart any skepticism, misconceptions, fear, resentment, or resistance that a vertical, "polio-only" approach might indirectly foster.

PCN emphasis on knowledge generation, quality research, monitoring, and evaluation helped to yield social data that contribute to understanding the behavioural and environmental factors that affect family decisions to accept or seek polio and routine immunisation in the region. For example, PCN assessments of clan structures and livestock markets revealed how information is exchanged within these structures, the linkages between these structures, and how these structures could be better used for health communication. Subsequently, these strategies were incorporated into the regional communication strategies (such as the collaboration with clan leaders for improved microplanning). All interviewed brokers expressed interest in supporting community health and development initiatives and responded positively to vaccination efforts in their communities. Some of the expressed needs to be further involved in health education included: "We need to have training about mother and children vaccines. We need someone to regularly work with us. Need per diem/incentive if possible." Some of the areas in which brokers were ready to support included: "To convey my communication about the advantage of the vaccine for both mother and child. Encourage other brokers to participate the implementation of the vaccination for mothers and children."

In conclusion: "With implementation of a strategic, context-specific, multipronged approach, children were more effectively reached. The experience and knowledge base generated by the PCN can contribute to better understanding of the factors affecting the demand for and uptake of health services in the Somali Region. Further, the PCN experience and achievements provide important lessons on how effective communication can advance the equity agenda in its efforts to reach all populations, particularly the most vulnerable, remote, or traditionally missed, with equitable health information and services for all. Finally, this documentation provides evidence of the PCN impact for the polio program and its future potential to support other child survival programs."