Author: Svea Closser, May 22 2015 - When polio eradication was proposed in the 1980s, many hoped that polio would be a "banner disease" that would raise awareness of and build enthusiasm for routine immunization (RI). So, RI was made one of the "four pillars" of the polio eradication strategy.

Over the years, though, this pillar has been left neglected in some places. In part, this is because of the perception that there is a limited time window for polio eradication to be achieved, and that RI improvements are too incremental and too slow. But after thirty years of polio eradication efforts, polio transmission is ongoing. So rethinking that approach - as many are - is timely and appropriate.

I worked along with a team of other researchers in 2012 on a project aimed at assessing the impact of polio eradication on RI and primary health care. We went to eight study sites in Sub-Saharan Africa and South Asia, learning about the relationship between polio eradication and other health services by spending time working with and interviewing the workers implementing these programs.1

One issue that was at the forefront for workers in several study sites was polio vaccine refusals. Refusals were common and vehement in two of our sites: Kumbutso Local Government Area in Kano, Nigeria, and in Karachi, Pakistan.

As an anthropologist, I'm used to thinking about these issues firmly in terms of local context. So I was surprised to find that the ways that people in Kano talked about vaccine refusals were very similar to the ways that people in Karachi talked about them. In both places, one issue was paramount: the heavy focus on polio campaigns in the context of weak health services.

In both places, health services have room for improvement (DTP3 coverage in the Nigerian region including Kano, for example, was just 9% in the last DHS before our research). But polio vaccination teams came door to door eight times a year in Kano and ten times a year in Karachi.

Here's what a health worker in Kano had to say about the situation:

"The members of the communities always complain about the constant visits to house-to-house mainly only on the polio activities.... Sincerely speaking, the public is so suspicious about the campaign on polio. People need malaria tablets more than polio vaccine....Some people complained that when fuel prices were increased nothing was done to console the poor, but when polio was rejected by the poor, the government and the community elders were used to persuade people to accept it....If boreholes and other essential amenities should be provided to these communities the polio vaccine would be more acceptable."

Health workers in Karachi made similar statements. For example, a UN employee noted that "some resist the campaigns not because they are against vaccination, but because they have other needs which the government is ignoring." And a mother refusing vaccination told us, "I cannot trust the polio workers and those drops that are given in the polio campaign. Polio campaigns should be stopped now. Routine immunization is a good thing. Medicine should be free, and there should be a doctor sitting in the clinic."

Given these sentiments, in polio's last strongholds, it seems to me that social mobilization strategies must ameliorate the mismatch between polio and other health services in order to be successful.

What would a realistic plan for this kind of communications strategy look like?

In our research, we found some strategies that work, built on polio's existing infrastructure. These best practices show that supporting RI through polio eradication is both possible and effective.

1. Provide other health interventions along with polio vaccine.

Probably the most obvious thing that those involved with polio eradication can do to support broader health issues is to provide a wider suite of services along with polio vaccine during polio campaigns.

Nigeria's attempt to do this shows the promise and the limits of this approach. Per the national policy, implemented in 2006 in Nigeria, during polio vaccination campaigns, door-to-door teams should provide not just polio vaccine but also vitamin A and incentives such as soap, sweets, and milk. Also, fixed points at health facilities should offer other vaccines, anti-helminthics, oral rehydration solution (ORS), and bednets.

In our study site in Kano, Nigeria, we observed this program in action. Its effectiveness was mixed. What actually made it door to door was mostly toys and sweets, while health interventions (including other immunizations) were limited to the fixed sites. So, people reasonably saw the items given door to door not as an attempt to provide additional health services but as a bribe to accept polio vaccine.

Some health workers said this worked well. Others reported a more reluctant acceptance. "Most people are forced to collect the vaccines unwillingly. Some take the vaccines because of the meager incentives given to them," one health worker said.

The program we observed might have had more success if it had included more health services delivered door to door. Doing that won't automatically alleviate community concerns, and of course cannot provide a replacement for comprehensive facility-based health services. Still, the power of campaigns to provide some additional services is potentially considerable.

2. Use outreach to marginalized populations during campaigns as a way to monitor - and then deliver - additional health services.

One of our study sites was Nizamabad, a district in Andhra Pradesh, India. In Nizamabad, there were several programs targeting hard-to-reach populations with immunization and other primary health services through mobile vans. But at the time of our research, these programs lacked sophisticated monitoring systems. Nobody knew exactly what coverage rates really were.

So, monitoring for these programs was added to the polio campaign. Campaign workers visiting migratory populations - including groups like pastoralists and temporary laborers working at brick kilns - collected information on RI coverage. A state-level official described this initiative as a plan to “reach each and every child....For routine immunization and pulse polio, both."

The program wasn't perfect - many of the forms in the campaign were not fully filled out with RI information. Still, it was a doable, potentially high-impact add-on to polio eradication activities. Strategies like this could also assess coverage of other key health services in underserved populations.

Of course this strategy only works in the context of programs reaching the populations in question with RI and other health services. The monitoring component in the campaign needs to be part of broader outreach efforts in order to have a meaningful impact.

3. Provide communication messages that go beyond vaccination.

Another case study site in India was in Purba Champaran, Bihar, on the border with Nepal. In Purba Champaran, there had been a sea change in public acceptance of all vaccines, including polio vaccines. People used to fear vaccination, people told us, but now they largely accept it.

This major change was probably driven by recent substantial improvements in health service delivery in Purba Champaran. But there was also a program called the 107 Block Plan, a far-reaching communications strategy that included a wide variety of activities, including measures like filling vacant medical officer positions to strengthen health systems.

Thousands of additional staff were hired in Bihar and Uttar Pradesh to disseminate specific, targeted communications messages about not just polio vaccination but also RI, ORS, breastfeeding, and handwashing.

Several blocks within our study district of Purba Champaran were included in the 107 Block Plan. A staff member there described her work:

"We are promoting hand washing....We are promoting breastfeeding. We are promoting zinc and ORS for controlling diarrhea. We conduct counseling meetings with the targeted families and slowly, slowly, it has developed awareness in their behavior....When we interact with families, our objective is to create awareness of environmental factors as well as their behavior."

The 107 Block Plan is a model worth replicating, as it targeted a range of root causes of polio transmission.

None of these communications strategies is a be-all-end-all; they all rely on concurrent provision of a wide range of health services to be truly successful. But they are likely to be more effective than strategies containing polio messaging alone. In the words of one communications professional working in India, "it has to be polio plus plus plus."

1 The results of that study, along with detailed recommendations and analysis in a web supplement, are available open-access here.