Report from the Communication Technical Advisory Group: Abuja, Nigeria

This Polio Technical Advisory Group (TAG) review was conducted in Abuja, Nigeria, by a team of 5 expert panellists and 4 observers between February 21 and March 3 2009. The panel first met with the National Social Mobilisation Working Group (SMWG) for a briefing during which key documents were shared and priority areas were identified for the team to focus on while in the field. Together they confirmed the urgency of the task, in light of the fast-approaching June 2009 deadline Nigeria's Minister of Health set for wild polio virus (WPV) interruption. In 2008, 803 children were paralysed by polio in 244 local government associations (LGAs) across 26 Nigerian states. The spread of poliovirus to southern states is another challenge, which also diverts attention and resources from the focused approach to interrupting virus transmission in the high-risk endemic north.

The National Primary Health Care Development Agency (NPHCDA)'s "Rapid Assessment of Social Mobilisation for Immunisation Plus Days (IPDs) KAP [Knowledge, Attitudes, and Practice] 08" highlights the lack of immunisation awareness amongst Nigerian mothers. While 63% are aware that polio can be prevented by immunisation 71% believe - falsely - that malaria can also be prevented by immunisation. While 54% of mothers believe that a child could suffer from paralysis if not immunised against polio, 25% believe that nothing will happen. Further, there are relatively low levels of polio information flowing to mothers from health workers as compared to neighbours, ward heads, or radio. There was a very low level of message recall, with 90% of mothers not able to remember a single message.

These samples "point to a significant knowledge gap and raise some questions about the role health workers are playing (or not) in providing high quality immunization information....[T]he relation between such a gap and the urgent need for addressing programme weaknesses in IEC [information, education, and communication] materials, training and training materials, strategic tracking and utilization of media and related strengthening of personnel levels and skill cannot be ignored."

That said, the panel found that there have been a number of successful communication initiatives undertaken since the 2007 Communication TAG meeting that provide important building blocks. The development of the "National Integrated Communication and Social Mobilisation Strategy for Immunization in Nigeria" is a notable recent step; this document served as a guide in the TAG team's deliberations and recommendations. Community dialogues, alliance building, and sensitisation have been used to reduce noncompliance - albeit in a fashion that has yet to be brought to scale (the Rapid Assessment notes that 87% of respondents were not aware of community dialogues). There have been recent developments in building political support, as well as increasing support from traditional and religious leaders at many levels.

As the report indicates, the Independent Monitoring Data (all participating states, inside house monitoring) show the general trend going back to January 2007 towards fewer missed children each round. However, while the general trend is accurate, actual numbers of missed children remain much higher. Furthermore, these levels of under-vaccination cannot be attributed to non-compliance. Rather, the central issue facing the programme is poor vaccinator-supervisor team performance: vaccinator teams not visiting households, immunising some children in households and not others, falsifying data, and communicating poorly with families.

Having examined the communication context, the panel offers a series of specific recommendations, along with "stepping stones" to guide and gauge progress (see the Appendix). For example, in the area of planning and human resources, the panel recommends the following at the national level: The United Nations Children's Fund (UNICEF) should complete its planned international recruitment in support of the polio programme by May 2009; UNICEF and the World Health Organization (WHO) should finalise deployment of LGA focal points for high-risk LGAs by March 2009; LGA facilitators should devote 50% of their time to supporting communication activities between rounds in areas where poor vaccinator/supervisor performance contributes to under-immunised or missed children (with monthly work plans reflecting this focus); and the Social Mobilisation (SM) Working Group should develop 2 measurable and time-bound communication objectives for review and endorsement by April 2009 on generating household and community demand for improved service delivery.

An excerpt from the report follows:
"We are, at the broadest level, recommending that the communication programme be reoriented to shift from its current, almost single focus on noncompliance to one that sharply increases the focus on communities and households reached by vaccinators but where clusters of children are left unimmunized....The communication goal is to make team performance a community as well as an operational issue. This will mean...enabling communities to recognise and demand good immunisation services.  Identifying those areas for increased communication attention will need to be driven by independent monitoring data that concludes that children are being missed, largely due to operational factors....We want to emphasise that we believe that work on noncompliance should continue but that it should be refocused on areas where there are significant clusters of noncompliance...

This will have implications for:

• Social mobilisation training
• Team selection and motivation
• Data use and analysis
• Between round communication
• Partnerships and alliances
• And the numbers of people we need on the ground to implement
  

...The strategy will rest on familiar communication elements:

• Advocacy
• Media
• IEC
• Training
• Social Mobilisation
  

It will focus on key strategies within the programme that are proving successful while building pressure from above through leaders and pressure from below at the community level. It will incorporate incentives for improved round performance and disincentives for poor performance. And it will utilise IEC materials, media and/or [interpersonal communication] IPC/CD training to support and acknowledge the backing of leaders, increase levels of demand for immunisation among communities and the commitment of those implementing the programme.

...To be successful the programme will need to enhance the present focus on advocacy with leaders so that political pressure for improved operational performance continues and builds while at the same time engaging the media to solidify political commitment, build community demand and raise awareness. IPC training strategies and materials have to be developed for vaccination teams focused on motivation and increasing community demand for improved immunisation services. Highly visible IEC campaign materials will need to be designed and rolled out which showcase support from community leaders, increase community level polio and immunisation knowledge and ensure awareness of the rounds. The scale of community dialogue and sensitisation training in poor performance areas has to be increased which will in turn require more people on the ground planning, tracking, supervising, coordinating and training. Consistent and well designed community dialogue and other IPC training will be required but with a focus on creating community demand for high quality immunisation delivery in HR areas where compliance is not a major issue but vaccinator performance is low. LGAs will need to establish performance recognition for vaccinators, supervisors and WFPs who demonstrate proven high levels of success."

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