"Marking a shift from the earlier dominance of epidemiological perspectives, today behavior-change communication - advocacy, interpersonal communication, and social mobilization - is recognized internationally as the way forward in this final phase of polio eradication."
This report: places the CORE Group Polio Project (CGPP) within the context of the Global Polio Eradication Initiative (GPEI) that began in 1988, defines and describes three varieties of social mobilisation (SM), and presents as case examples CGPP's SM work in India, Angola, and Ethiopia to reach difficult-to-access populations critical for polio eradication. These include extremely economically poor rural and urban communities, ethnic and religious minorities who resist immunising their children, and others such as newborns, pastoralists, migrants, and those in transit across national borders. The report is intended for those interested in best practices to move polio eradication from its current 99.9% success rate to 100% and all who want to "reach the hardly reached" with routine immunisation (RI), new vaccines, and other life-saving maternal and child health services.
In an effort to help in designing and evaluating health programmes that include SM, the report draws on the work of Rafael Obregon and Silvio Waisbord, whose analysis of the literature, case studies, interviews, and on-the-ground observations led them to identify 3 kinds of SM used in polio eradication efforts:
- Pragmatic SM, which seeks to involve community actors through activities such as: meetings with political, community, and religious leaders to obtain their cooperation and prepare them to communicate polio messages to their constituencies; training outreach workers to go door-to-door to persuade caregivers to bring their children to the vaccination booths during campaigns; or involving the community in surveillance and reporting of polio cases. While these activities have been very successful in increasing the number of children immunised, "these approaches are seldom enough when there are populations resistant to polio immunization. Nor would pragmatist approaches be likely to sustain the motivation of key community actors to continue undertaking polio or other child survival activities after a project ends."
- Activist SM, which is "the wresting of decision-making power from global or national direction to local communities who identify their own goals and strategies. An underlying challenge of this approach is that it may be threatening to governments to encourage marginalized populations to become advocates for their rights."
- A hybrid SM that combines both pragmatic and activist elements.
"In every country where it works, CGPP's field work exemplifies a successful hybrid of pragmatic and activist SM." In sum:
- In India, to reach high-risk populations, CGPP has joined with the United Nations Children's Fund (UNICEF) and the National Polio Surveillance Project to deploy a network of Community Mobilization Coordinators (CMCs), frontline workers who interact with their own community. In brief, their SM activities include: tracking newborns and children, visiting homes, engaging high-level community leaders in both Muslim and non-Muslim neighbourhoods, involving community groups (such as women's groups) and individuals, working with schools and students (e.g., by giving classroom talks about the importance of immunisation), putting community creativity to work (e.g. by organising street theatre, dancing and singing events, and art shows that convey polio messages), broadening the scope beyond polio (e.g., communicating messages about RI, handwashing, and nutrition, etc.), and reaching mobile populations. Related activities have included: training and mentoring in interpersonal communication (IPC), working with the mass media, developing and pre-testing materials such as posters and pamphlets, integrating activities with the local health system, and capitalising on trust during Supplementary Immunisation Activities (SIAs).
- In Angola, CGPP's community volunteers undertake these SM activities: engaging community groups and leaders (e.g., collaborating with media officials), carrying out home visits that involve one-on-one counselling, providing health education (in the form of talks, radio shows, puppet shows, etc.), partnering with the military to assess how well the SIAs reach children, and strengthening community surveillance skills. Activities that support SM in Angola include micro-planning for SIAs and supporting local Ministry of Health (MOH) facilities for RI, SIAs, and acute flaccid paralysis (AFP) surveillance.
- In Ethiopia, the volunteer outreach workers are called Community Volunteer Surveillance Focal Persons (CVSFPs). Their SM actions include: house-to-house focused counselling on RI and SIAs specifically reaching out to newborns and defaulters, child tracking for AFP as well as other vaccine-preventable diseases, influencer involvement, group education sessions on SIAs and RI, teacher and student (including peer-to-peer) engagement, pastoralist outreach, and cross-border collaboration. Related activities to strengthen the health system include: regional advocacy workshops, technical assistance for micro-planning, campaign activity support and monitoring, meetings with local health workers, and educational materials on polio immunisation, RI, and surveillance.
Based on these case studies and some of the research data shared in each section, the report asserts that: "Working through grassroots NGOs [non-governmental organisations] in developing countries, CGPP and its collaborating partners have made significant contributions through strategic social mobilization in high-risk communities, most notably helping to achieve the current polio-free status of India, Angola, and Ethiopia. Applying lessons learned from these case examples could make a critical difference in other countries. Such lessons would also greatly inform other programs that seek to engage the whole community in order to make a transformative change." Eleven lessons learned are elaborated in the report; in brief, they include:
- Use research to tailor messages to the context of people's lives.
- Make the link between national priorities and local action.
- Reach the people repeatedly with key messages.
- Be persistent.
- Implement activities targeted to a specific disease in a way that supports and strengthens related health services.
- Devote time to the selection, training, and support of community-based outreach workers.
- Advance the participation of women as social mobilisers, vaccinators, surveillance officers, and leaders in polio eradication efforts. ("Women influentials who speak out about vaccinating their own children serve as role models for children's caregivers - typically women - to emulate.")
- Involve children in campaigns to help counter "campaign fatigue" and alert and motivate caregivers to immunise their children during SIAs.
- Recognise that partnership is powerful.
- Select highly respected and well-connected individuals to direct the country project; this enhances the likelihood of having "a place at the table".
- Involve NGOs as central players.
Email from Karen LeBan to The Communication Initiative on October 9 2012. Image credit: © CORE Group Polio Project India