Conflict, Community, and Collaboration: Shared Implementation Barriers and Strategies in Two Polio Endemic Countries

"The power of community engagement at all levels (from leadership to membership) cannot be overstated, particularly in countries facing civil unrest and insecurity."

Despite efforts over decades by the Global Polio Eradication Initiative (GPEI), transmission of wild poliovirus (WPV) is ongoing in Afghanistan, and circulating vaccine-derived poliovirus (cVDPV) is still occurring in Nigeria. Despite their unique sociocultural characteristics, these countries share risk factors for the spread of polio, including civil unrest and conflict; vaccine refusals, mistrust, and fatigue; and competing political agendas. This paper shares research conducted by the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) consortium (see Related Summaries, below) and highlights lessons on implementing polio eradication activities among hard-to-reach populations relevant for future global health programmes.

STRIPE conducted a grey literature review of the GPEI, followed by an online survey of individuals who have been involved continuously in polio eradication activities for 12 months or more since 1988 (513 in Afghanistan and 921 in Nigeria). A subset of respondents from the survey was recruited for semi-structured key informant interviews (KIIs) - 28 in Afghanistan and 29 in Nigeria - using a tool designed from the Socioecological Model (SEM), which considers the complex relationships between factors that influence the individual, interpersonal, organisational, community, and larger environment. The survey and KIIs were conducted between September 2018 and April 2019. A cross-case comparison analysis was then conducted.

Case Study: Afghanistan
The majority of respondents (80%) reported experiencing external barriers while attempting to eradicate polio in Afghanistan. Political and social factors constituted over 60% of all reported external barriers (42.8% and 25.2%, respectively). External context emerged as the most significant challenge for those involved in community engagement (67% of all barriers cited). More specifically:

• Eradication efforts in Afghanistan have been complicated by civil unrest and insurgent occupation, which makes some areas inaccessible to health workers, who fear for their safety and security. One solution has been coordinating with different opposition groups to gain access to unsafe areas ("Days of Tranquility").
• Political leaders in these conflict-affected areas have faced competing political priorities, balancing politically savvy messaging and other health priorities for the country.
• Continuous engagement with communities in conflict areas has been an important strategy. Communities in Afghanistan were mobilised by engaging religious and community leaders and social mobilisers, who enlisted local influencers to support vaccine campaigns. Advocacy visits to these leaders helped improve communication and assuage religious and social concerns. Preliminary, secondary, and high-school students also served as community mobilisers, increasing awareness of the polio vaccine among their immediate family members and friends. KII respondents stressed the importance of knowing the community well to reach every child. This included not only having the trust of the community and familiarity with community leaders but also with the settlement, the streets, and the households.
• Social barriers, especially mistrust and rejection of the polio programme, emerged as the largest external barrier. For example, KIIs revealed that some people are concerned that workers are disguised government agents and that door-markings placed by polio workers (e.g., indicating that the team has visited the house) are intended for drone attacks. The country has also experienced substantial programme fatigue among both health workers and community members; in some areas, community members demand other health services because polio drops are the only service the communities receive. In addition, communities have historically been resistant to receiving services from male workers, so the programme has actively recruited and employed female workers.

Case Study: Nigeria
The majority of respondents - 602 (62.3%) - reported experiencing external barriers; for example, the external context was identified as a barrier by 40% of those involved in community engagement. In more detail:

• Militants of the Boko Haram in Northern Nigeria have actively threatened the safety of polio workers. Among the programme responses: asking military personnel to adapt to either serve as health workers (with some basic training in vaccination) or to serve as escorts to health worker cadres. Some immunisation campaigns were conducted without any prior public announcements; health workers discreetly went into communities, vaccinated as many children as possible within a stipulated period, and then left.
• The Nigerian government has historically been supportive of the polio programme and provided high-profile endorsements. However, these efforts have been met with complaints about the polio programme conflicting and occasionally overlapping with other health programmes implemented at the state and local government levels.
• Community engagement approaches were widely lauded in the KIIs as solutions to reaching hard-to-reach populations. For example, respondents highlighted the critical role of gaining the trust of the community members and establishing relationships with community leaders and others who are familiar with the communities, including how to locate streets and households.
• Survey respondents identified social barriers to the programme as the largest external barrier. This is evidenced by the mistrust and rejection of the programme activities and health workers by community members. These factors, coupled with fatigue, have amplified low turnout for polio campaigns and routine immunisation.

Thus, this research found that major polio eradication activities in both countries include house-to-house campaigns, cross-border stations, outreach to mobile populations, and surveillance. Common barriers to these activities in both countries include civil unrest and conflict, competing political agendas, and vaccine refusal, fatigue, and mistrust - all of which can complicate efforts to access hard-to-reach populations. Both countries employed strategies to engage community leadership and political and religious groups through advocacy visits, as well as to involve community members in programme activities to address misconceptions and distrust. Recruitment of female workers has been necessary for reaching women and children in conservative communities (e.g., in Northern Nigeria). Synergy with other health programmes (e.g., the response to the Ebola epidemic in West Africa) has been valuable in improving health workers' knowledge of the communities they serve.

Among the lessons learned: "To maintain engagement with hard-to-reach communities, disease control and eradication programs should leverage and fully support existing resources (from individuals to organizations) to meet the wider needs of these vulnerable populations."

In conclusion: "The polio programs in Nigeria and Afghanistan have struggled to reach environmentally and socially hard-to-reach populations. Engaging stakeholders early and often, even those with extreme opposing views, is key to success. These countries' shared lessons learned in navigating conflict and insecurity through collaborative approaches and community engagement can be brought to bear for other health programs seeking to facilitate access and achieve robust coverage."