In the course of recent reviews of the Polio Eradication Initiative (PEI) in Pakistan and Afghanistan, two things occurred to me about the communications and social mobilisation component of both national programmes. First, attention to social data (evidence-based analysis of the attitudes and behaviour of households confronted with the possibility of polio vaccination) has improved enormously in recent years.
Second, however, analysis of the causes of poor programme performance (high rates of missed children) is still too narrowly conceived and operationalized. Research supporting polio communications seems to focus heavily or exclusively on the knowledge, attitudes and behaviour of eligible households - as if the behaviour of households when confronted with the possibility of polio vaccination is the result, uniquely, of knowledge and attitude, and not of other, more material circumstances that determine what kinds of behaviour are practically possible. In a corollary fashion, research protocols appear to investigate household knowledge, attitudes and behaviour as if polio were the only - or at least most central - concern in the lives of households which, in reality, struggle with a hundred more pressing and pertinent issues every day.
Social research supporting polio eradication appears to err in two respects. First, it often concentrates exclusively or primarily on household knowledge of and attitudes to polio and OPV, without asking wider questions enabling us to understand not just how households think about this disease and its vaccine, but how - in a relative sense - households position polio and the opportunity (or threat) of vaccination in the long list of other priorities, threats and opportunities which they spend much of their waking lives trying to navigate. Second, it focuses on knowledge as the key driver of behaviour, without taking sufficient account of the much broader material conditions that shape that behaviour, and the wider systems and institutions that expand or constrain those conditions.
Of the things we know for reasonably certain about the world, health and polio eradication, here are three:
- First, the technical and operational proposition of vaccination and mass immunisation have, throughout their history, been the subject of - and caught up in - complex networks of social, economic, political and cultural interest (Allen, 2010; Taylor, 2009).
- Second, behaviour - the subject of much public health interest in producing health outcomes – is the end product of a complex range of determinant factors, including both norms and values and the material conditions in which people live - themselves shaped by national systems of governance, policy and resource distribution (WHO, 2008).
- Third, increasing heath information through communication alone does not enable behaviour change across society - instead, evidence shows that those with material and social resources (i.e., not poor, not marginalised) are able to convert messages into effective behaviour change, while those without cannot. In this instance, health communication without substantial change in material resource access can actually increase inequity in heath behaviour and hence health outcomes (King’s Fund, 2012).
Yet communication and social mobilisation activities supporting polio eradication often appear to operate as if behaviour can be changed without attention to the material resources that make new behaviour marginally preferable and possible; that attitudes to polio exist - and can be addressed - as a unique phenomenon, separate from wider and complex socio-economic and political issues; that the world of the eradication programme can be somewhat neatly divided between us (who understand and support polio eradication) and them (who are the subject of the programme’s vaccine delivery).
Communication for polio eradication can be strengthened in three ways:
- First, generating a more textured analysis of the national and sub-national political, economic and institutional context in which the eradication programme happens.
- Second, exploring ways in which communications can be used to change and enhance the material conditions of the lives of those people targeted for vaccination.
- Third, understanding the complex and often multiple identities and attitudes of key actors and interlocutors in the polio eradication programme, in order to target communication interventions within the programme’s core constituency - its health workers and vaccinator teams.
Mass vaccination programmes such as PEI will benefit from better, more sophisticated political economy analysis. Here are three suggestions as to how communications and social mobilisation concept and practice can be strengthened both in the case of polio eradication in the remaining endemic countries, and in future mass vaccination programme design and roll-out.
Develop a political economy of 'state', development, and health
Mass immunisation - increasingly so as it is applied in countries with limited resources and fragile institutions of governance - provokes contest between factions including international actors, government agencies, religious and ethnic leaders, civil society, community leaders, health practitioners and families struggling to manage increasing risks often with diminishing resources. In order to understand the context in which a national eradication programme will develop, thrive or fall short of its ultimate objective, we need to understand how and where the target disease sits in the often contested field of discourses of health - where medical practitioners defend their business interests by challenging publicly funded health institutions regarding vaccine efficacy and appropriate modes of delivery; where traditional health practitioners defend the validity of their approaches by questioning vaccines as a general technology; where religious and ethnic factions critique the value, safety and transparency of a mass vaccine programme as a way of engaging and expanding popular support by challenging entrenched government elites.
But we also need to understand where health sits within wider national political discourse. In order to help shape a governance system supportive of polio eradication, the polio programme - in particular its communication and social mobilisation component - must understand and engage with the wider political economy. Because it is this wider political economy that will shape not only the way the state (nationally and locally) defends, support and resources health services in general and vaccination in particular, but also the kinds of material improvements at community and household level that may positively influence families’ ability and willingness to commit to polio vaccination.
Develop a political economy of household health
Much programme research is designed to investigate how people and households think about polio. Yet polio is frequently very far from the centre of gravity of people’s lives in target communities with high rates of missed children in remaining endemic countries. Marginalisation, a bleak absence of economic opportunity, a dearth of public services, deep-seated fractiousness and suspicion between communities, between social groups, between people and government - these are the core features of household life and daily struggle. To assume that, with some encouragement, explanation and ‘mobilisation’, households will collectively shift from overwhelming lack of interest in polio vaccination to popular collective activism in support of the programme is naïve at best.
Understanding where polio fits in people’s lives - how vaccination articulates with wider interests, aspirations and fears - is key to understanding first the limits of communication (the extent to which messages from the polio campaign are simply insignificant relative to other more pressing matters), and second the kinds of messages that have any chance at all of touching and provoking positive associations and responses. Yet most social and communications-related research starts from the premise of polio as a key interest or point of reference for households targeted for investigation. The result is information that is more reflective of the assumptions and biases of the investigators than of the reality of the lives of the respondent families. The resulting concepts of communication, again, reflect assumptions on the part of the communicators, and much less an attempt to engage seriously with the complex and frequently life-threatening realities of daily life among those we hope to persuade that vaccination is a worthwhile thing to do. Simply massaging imagined aspirations is unlikely to get more than a polite reception and affirmation of pre-existing support for vaccination.
Develop a political economy of the health system
Third, the conventional supply-and-demand model underpinning polio programme design and analysis, imagines a world neatly divided into 'us' (the programme) and 'them' (the target population), with each construed as a more or less homogeneous group, informed about polio and supportive of the initiative, and un- or misinformed about polio and only latently supportive, respectively.
This over-simplification misses out a critical 'community' who occupy the no-man’s land which lies between, and connects, supply and demand - the front-line health worker cadres, whether quasi voluntary or salaried within the system.
These people - in the case of the polio eradication initiative often a periodically assembled amalgam of local health workers and local 'volunteers' (students, community residents, CSO affiliates seeking a small payment or recruited under obligation by local notables) - are the critical human element of the global eradication programme. Their commitment to polio vaccination is often assumed; their commitment to the programme, and their commitment of energy to getting the job done often treated to what can best be described as cursory investments in the form of training and emoluments.
Recruited from the communities they are supposed to target, volunteer vaccinators likely share much of the ennui of their target households when it comes to OPV. They likely share the same narratives of suspicion regarding the intensity of campaign rounds (and their own repeating recruitment). They may share the same scepticisms passive or otherwise regarding dose after dose of OPV (without having for a moment to dip into the darker narratives of Western plotting and poisoned vaccine). Diverted from other commitments, health worker vaccinators may share the ambivalence of their superiors within the health system to the perceived drain on resources effected by a programme dealing with what is sometimes perceived to be a more or less negligible health problem. They may share the alternative health models of some of their local health counterparts, casting doubt on the efficacy or value of OPV.
This has to have an effect on delivery - and indeed we see that delivery is now increasingly acknowledged as a key element of the failure of the programme to reach its last remaining targets. Yet communication and social mobilisation aimed at understanding and engaging with this vital constituency – where supply and demand meet - is limited at best.
Is this kind of analysis the proper remit of polio communications? Evidence in practice suggests that the national programmes - increasingly in the final endemic countries - tend to 'firefight' emerging incidents of institutional or popular programme failure, and to address acute issues arising in the polio programme, with much less attention to structural and systemic factors.
Yet the analyses recommended here are very much needed to strengthen polio eradication and future mass immunisation campaigns. They are very much the province of communications and social mobilisation - the element of the polio initiative that attends explicitly to the social context of technical vaccination, and to strategies to make that context supportive of vaccine delivery and consumption. Without these analyses, the programme will continue to found itself on somewhat simplistic assumptions about threats and opportunities from the wider political, economic and institutional context; it will continue to under-estimate the nature and causes of missed children at the household level, and hence to derive strategies only ever likely to be partially effective in changing household behaviour; and it will continue to generate research, monitoring and evaluation protocols at household and community levels which reveal a continuing - and apparently mysterious - disconnect between what people say they know and think about polio and OPV and how they behave when the vaccinators show up.
By Seb Taylor, Independent Consultant on Health and Fragile States
 In the case of Pakistan, for example, three distinct discourses of ‘the state’ can be identified – the ‘security state’, the ‘democratic-developmental state’, and the ‘religious state’. Since partition, the discourse of security as primary state concern has dominated (IDL, 2011).