Critical Leap in Polio Eradication in India

As of June 2003, polio continued to threaten the health and lives of children in seven countries: Afghanistan, Egypt, India, Nigeria, Niger, Pakistan, and Somalia. This 84-page report traces the history of one of these country's efforts to eradicate the crippling disease. It explores the communication strategy used in India's polio eradication programme, which incorporated social mobilisation. UNICEF defines this term as "a broad-scale movement to engage people's participation in achieving a specific development goal through self-reliant efforts. It involves all relevant segments of society: decision and policy-makers, opinion leaders, bureaucrats and technocrats, professional groups, religious associations, commerce and industry, communities and individuals."

Specifically, the paper examines the context, process, and impact of India's initiatives, which were carried out in collaboration with UNICEF. As implied by the above definition, partnership was a key element of this effort: high-level political advocacy, mass media campaigns, social marketing, and mobilisation of government and non-governmental institutions all played a role. In Uttar Pradesh (UP), the epicentre of the disease, UNICEF also supported the assembly of an interpersonal communication channel known as the Social Mobilization (SM) Network to reach marginalised, underserved, high-resistant, and high-risk communities. Patterns of, and reasons for, resistance at various points throughout the initiative are also detailed here.

The following excerpts from the paper explore the motivation behind the social mobilisation activities that have been developed and that are described in detail in this paper.

"Communication and social mobilization strategies, prior to 2000, were focused largely on raising awareness. As it became clear that the 0.7% of children unreached, unvaccinated or inadequately vaccinated could hold up India's eradication goal, and set back the enormous progress made, a revision of strategies and messages was necessary.

"The challenge confronting the government, UNICEF and the Social Mobilization Working Group was two-fold. Firstly, how to bring information to the unreached,
underserved communities and tackle resistance to OPV [oral polio virus] vaccination? Secondly,
how to continue motivating the majority already reached to participate in OPV vaccination for the next two years.

"The marginalized, underserved communities were ones with little or no access to the mass media, and most vulnerable to doubts and rumours about OPV. These were also places where ANMs [Auxiliary Nurse and Midwives] showed up only to administer polio drops. One might believe it would be easy for MOHFW [Ministry of Health & Family Welfare] to put pressure on them to perform. The nature of disease eradication, however, was more than routine work. It required a high degree of commitment from all involved, in particular ANMs, health workers and house visit supervisors, to sustain the search for unvaccinated children. Even for those who diligently carried out their duty, the frequent rounds of immunization in 2000 had left many feeling exhausted and daunted.

"Lax supervision within the system also affected their morale...

"The formation of a special outreach team to interact with families, using persuasion to reduce resistance to lay the ground for vaccinators' visit was thought a workable solution. The Social Mobilization Working Group proposed the plan to the Interagency Coordinating Committee, and UNICEF agreed to finance the outreach effort. Thus for the new rounds of vaccination in 2001 - 2002, a judicious mix of mass media and interpersonal communication approaches was adopted. The objectives:

i. Raise awareness, and change parental attitude and behaviour in high risk districts of UP and Bihar

ii. Inform and remind people of new NIDs [National Immunization Days] and Sub-NID dates

"The combination of approaches was termed, within UNICEF, programme communication: 'A research-based, consultative process of addressing knowledge, attitudes and practices through identifying, analyzing and segmenting audiences
and participants in programmes, and provide them with relevant information and motivation through well-defined strategies, using an appropriate mix of interpersonal, group and mass media channels, including participatory methods.'"

This paper also provides data from various phases of India's polio eradication efforts in the form of figures, charts, and tables. Among the impact data shared:

"Over the months, between November 2002 and January 2003, the SM Network with its full-scale involvement of partners and communities themselves, had contributed to the state-wide results as follows:

• An increase in the number of children vaccinated from 30.48 million in November 2002 to 33.96 million in February 2003;
• An increase in the number of children vaccinated at booths from 8.77 million to 14.70 million over the same period, representing a 67% rise overall;
• Decrease in the percentage of 'False P' houses [vaccinators had, falsely, concluded "Pass! Children were already vaccinated"] from 8.5% in April 2002 to 3.4% in February 2003;
• Decrease in the total missed houses from 11.9% in June 2002 to 6.8% in January 2003, but increased to 7.8% in February 2003
• A fluctuation of % X-marked houses [no one in the house during vaccinators’ visit; door was locked during vaccinators’ visit; or some children not immunised, vaccinators to return], however, from 3.5% in June 2002 to 4.4% in November 2002, and down to 3.5% in January 2003 but went back up again to 4.4% in February 2003."

Lessons learned are also detailed here. To cite only one: "An important lesson - as India built on its current success - was the need to engage the forgotten, the marginalized, now the focus of attention in the battle against time to accomplish a goal they had not come to share. For UNICEF and its major partners, the experience gained from using communication to induce behavioural change among the underserved had brought a new meaning to the task ahead. Resistant communities had responded to the full range of interventions that addressed their fundamental needs for information, knowledge and services, albeit delivered only for a time, by the SM Network to respond to the polio emergency."

Editor's note: footnote numbers were omitted from the above selections.

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