Engaging the Last 1% in Pakistan - Communication Strategies to Ensure: Access, Security, Trust

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Publication Date
November 28, 2013

Behavioural outcome: Every child is vaccinated with the oral polio vaccine (OPV).

Delivered at the Pakistan Technical Advisory Group (TAG) on Poliomyelitis Eradication, which met in Islamabad from November 27-28 2013, this presentation outlines:

  • Social and operating context of communications in 2013
  • Key results: advocacy, media engagement, social mobilisation, and challenges and risks
  • The way forward in 2014

In order to ensure that every child is vaccinated with OPV, the Pakistan polio eradication programme has developed an integrated communication strategy that includes:

  • information, education, and communication (IEC) materials and mass communication;
  • social mobilisation (COMNet);
  • outreach to high-risk groups;
  • media engagement;
  • advocacy and private partnerships; and
  • interpersonal communication (IPC) training of frontline workers.

As explained here, in the past, communication for polio eradication in Pakistan involved: high intensity, high visibility, campaign-focused public information/mass media campaigns; social mobilisation efforts with door-to-door focus; and a polio-focused media and mass media strategy. However, in 2013, the strategy changed due to the observation that, of the 2013 wildpolio virus (WPV) cases, 89% of those were in Pashtun children, and 90% were from 4 Pashtun tribes. "We are consistently missing - or unable to reach - these tribal children with OPV." In 2013 (as of this presentation), 76% of cases were in insecure areas; in 2012, that percentage was dramatically lower (31%). Amongst the communication challenges were messages released such as this one (from Hafiz Gul Bahadur, North Waziristan militant commander, June 2012): "We don't want benefits from well-wishers who spend billions to save children from polio, which can affect one or two out of hundreds of thousands, while on the other hand the same well-wisher (America) with the help of its slave (Pakistan's government) kills hundreds of innocent tribesmen including old women and children by unleashing numerous drone attacks. The ban on vaccinations...would not be lifted until the drone strikes stop."

Communication strategies and activities are discussed. Approaches involved creating incentives for all actors to participate and "win" by eradicating polio, engaging parliamentarians from all parties, and identifying civil society activist champions to condemn attacks on polio workers, profile these workers as "protectors of children", and build trust/demand for polio and routine immunisation (RI). The presentation gives examples of specific advocacy activities. For instance, in preparation for the May 2013 election and as a follow-up to the All Parties Conference (APC) for Polio Eradication held in December 2012, four individual meetings were conducted with mainstream political and religious-political parties. All the parties unequivocally supported the polio eradication initiative; many included specific references in their party manifestos. The statements of the political leaders announcing support for polio eradication were prominently covered by the media. As a follow-up to this APC, a meeting with the parliamentary heads of all politically elected parties was organised on July 15 2013 to revitalise the political commitment. Technical experts from the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) presented an overall update of the polio eradication initiative in Pakistan, on behalf of the government. Representatives of nine political parties attended the event. The participants reiterated their commitment to the polio eradication effort and also highlighted the need to strengthen the vaccine management systems in Pakistan, as well as the need for accountability and strict monitoring of the programme at all levels.

A "speaking book" titled "A Story of Health" was produced in partnership with Rotary International. The book contains messages on polio prevention, hand washing, nutrition, safe water, and hygiene and sanitation. The voiceover is in Urdu and Pashto languages for use by school children and mothers in reservoir areas. The speaking book was launched on World Polio Day on October 24 2013. That same day, nationwide vigils were held to remember and honour victims of the attacks on polio workers and security personnel.

Throughout 2013, media engagement activities included capacity building (300 journalists trained in high-risk areas, or HRAs), focused engagement in HRAs (one-on-one meetings with key media decision makers to raise threat perception of polio), and targeted media partnership to reach high-risk groups. In addition, efforts were made to address negative tonality (through one-one-one meetings with editors of publications misreporting on polio), promote positive coverage (provincial media officers reporting ahead of and during campaigns), and engage religious editors in support of polio and RI vaccination. Perhaps due in part to these activities, from January through November 2013, there were 6,340 print articles and 875 electronic reports on polio coming out of Pakistan (reaching both decision makers and caregivers in the English press and Urdu press) - with coverage of polio overwhemingly positive.

The presentation shares data on OPV refusal and explores reasons for this in different areas of Pakistan, such as circulating rumours that led a Karachi father to turn against polio vaccination, leading to the first case of polio in the country in 2013. Religious reasons also figure prominently. Promoting OPV and engaging with refusal families has involved increasing risk perception to the polio virus through mini-documentaries featuring real polio stories broadcast across Pakistan, mass media and media engagement to address religious refusals, voice-automated text messages sent by religious influencers to caregivers through partnership with Zong Telecom, and attempts to address misconceptions through medical influencers and health material that promotes OPV and RI.

It is noted that the government is taking leadership on communications. For example, in Federally Administered Tribal Areas (FATA), and it is proposed for other reservoirs, COMNet staff is being issued government identification (ID) cards to foster a feeling of ownership, delinking the polio programme with international partners, and providing a sense of security.

All social mobilisers deployed in Pashtun areas of Pakistan are from local areas and speak Pashtu; nearly half of COMNet staff are from 4 key tribes. To that end, the strategic shift in 2014 will be to integrate Pashtun social norms into all components of communication strategy (e.g., amplifying Pashtun voices into the national media discourse and minimising Global Polio Eradication Initiative (GPEI) voices) - with a focus on reaching key tribes. The idea will be to position polio vaccination so that community, political, and religious leaders view OPV as an essential trusted commodity - one that they would not consider bartering in exchange for other demands or cessation of drone strikes. Another focus will be on building family and community demand for OPV among populations who currently accept OPV (the 99%), among resistant families and population groups within accessible areas, and in inaccessible areas or where health workers' lives are threatened.

Communication challenges and risks are outlined. They include issues such as lack of trust in the polio programme, COMNet composition (male social mobilisers are unable to enter household compounds, and only 23.33% of social mobilisers are female), refusals, gaps in social data, and poor IPC skills among vaccinators.

Click here for the 46-slide PowerPoint presentation.

Source: 

Email from Chris Morry to The Communication Initiative on February 5 2014.

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