From Crisis to Opportunity: Report of the Polio Communication Review

"The spike in refusals and public expression of anger and doubt at the efficacy of the vaccine can only be described as astounding....Recovery will take time."

This report emerges from an April 2019 review that was designed to assess the state of communication for poliomyelitis eradication in Pakistan and to make recommendations to the country's polio programme. Even before the review, refusals of the oral polio vaccine (OPV) had been steadily growing for some time; the crisis that began unfolding in April 2019 only exacerbated - exponentially so, in fact - the already-daunting communication challenges. The review team is concerned that the consequences of this incident are likely to be long-lasting and may even extend to the overall Expanded Programme on Immunization (EPI) in Pakistan, as well as to the other remaining polio-endemic country, Afghanistan. A long-term strategy is needed to regain and sustain public trust.

In short, on April 22 2019, several staged videos went viral on Twitter and Facebook falsely claiming that children had become gravely ill after their polio vaccinations in the province of Khyber Pakhtunkhwa (KP) in northwest Pakistan. Through various charts and graphs, the report examines the impact of that incident on OPV refusals in different provinces, noting that KP, KP Tribal Districts (KPTD), and Balochistan were among the most affected.

Despite this, the review team acknowledges the valiant efforts the programme has made to respond to most of the recommendations that have been made by the last polio communication review, internal reviews and missions, and the Technical Advisory Group (TAG). For example:

• Progress has been made in the area of data analysis through the creation of challenge mapping tools, union council (UC) profiles, and better integration with microplans. The monitoring and evaluation (M&E) team has begun a review to rationalise and remove unnecessary data gathering.
• New cadres of staff with stronger communication skills (e.g., civil society organisations, or CSOs) have been introduced, with pilots in Peshawar and Karachi. They have shown potential but need to be fully reviewed for impact.
• The programme now has a social media cell; a review of its role during the April 2019 crisis would be useful.
• Training is being revised and updated.
• New materials are being developed.
• A new mass media strategy is being developed to emphasise risk and maintain a supportive environment towards polio.

The review team asks why the situation is as dire as it is in Pakistan, even in light of the progress that has been made. They cite two main reasons, which they note impact almost every element of communication for eradication (C4E):

• Intense supplementary immunisation activity (SIA) schedules are impacting community-based vaccinators (CBVs)' ability to fully implement communication plans, particularly those involving sustained, evidence-based community engagement - not only for refusal and missed children conversion but for building and sustaining support for polio vaccination. The review team observes that the recent addition of CSOs to the CBV structure has increased capacity to plan and implement evidence-based community engagement activities between rounds, but CSOs are still in the pilot phase and few in number.
• The SIA schedules are further amplified by multiple knocks on the door, increasing the amount of time spent on communication related both to the immediate goal of immunising children at the point of contact and to the number of times households come in contact with the polio programme at their doorstep. The impact of so many rounds and door-knocks can be seen not only in some parents' animosity toward the programme but also in knock-on effects, such as a lack of time to focus on alliance and partnership building.

In light of these findings, the team offers the following 9 recommendations:

1. Review interpersonal communication (IPC) strategies in light of the fact that IPC at the doorstep is critical but cannot stand alone - IPC should be reviewed to look into how it can change to incorporate more social and behaviour change (SBC) principles and techniques as a way of making this engagement more positive.
2. Create and protect space for C4E, reducing the number and improving the quality of knocks on the door - Among the options for doing this the review team proposes would be to expand the CSO cadre so that it can carry out C4E activities without being drawn into vaccination activities.
3. Collect and disseminate qualitative and quantitative data only when needed - Per the review team, the programme needs to reduce the data collection burden on frontline workers (FLWs) and to ensure that each level receives and analyses only the data it needs. Furthermore, challenge mapping, UC profiles, and microplanning initiatives need to be fully rolled out across the programme with further training, supportive supervision, and review to ensure no duplication of data gathering. One data-gathering endeavour the review team deems essential: An analysis of the relation between campaign spacing and impacts on numbers of still missed children that incorporates not just SIAs but also other campaign events.
4. Improve coordination of existing communication structures and resources - For example, within the Community Mobilizer Network (COMNet), which pre-dates the CBV cadre, roles, responsibilities, and accountability need to be further clarified to ensure that the communication elements of social mobilisers' work are respected and protected. Similarly, formal training for religious support persons (RSPs) needs to be strengthened to improve their motivation and give them more communication skills for fostering community support for polio and for engaging in advocacy with their peers (e.g., they should be provided with information, education, and communication (IEC) materials and tools appropriate to their roles).
5. Create stronger alliances/partnerships that will help build more social capital and foster long-term relationships - The issue, in short, is that "The spread of rumours and misinformation coupled with widely shared concerns about vaccine safety and efficacy and the perception that the program is driven by an international rather than a Pakistani agenda have begun to coalesce to create a context which makes it harder for the polio program to defend itself without support from other sectors of Pakistan society." Thus, the programme is advised to urgently map out and prioritise a small number of strategic social allies and to engage them with a well-thought-out advocacy and partnership plan. The review team also recommends developing a plan for identifying and engaging a wider range of local-level influencers - e.g., teachers, local politicians, and - to, for example, act as advocates for the programme and enablers of pro-vaccination sentiment within their communities.
6. Engage all levels of government - Such efforts can provide an opportunity for working together with sectors outside of polio as well as advocacy opportunities that underline how the polio programme is shared and supported by the government at every level and across political parties.
7. Reintroduce community engagement and advocacy strategies that utilise SBC approaches - In the case of refusal, "influencing" the parent to accept the drops requires a give-and-take process that requires patience and time and allows space for people to voice their fears and consider their possibilities. To help programme staff understand this longer-term and more interactive type of engagement, the review team asserts that a senior-level workshop should be held (possibly led by SBC experts from outside the programme) to redesign approaches to incorporate SBC principles and approaches. Furthermore, they indicate that communication staff at all levels should be trained in SBC approaches and activities, with C4D teams given more flexibility to systematically plan, execute, monitor, and account for (using measurable outcome indicators) SBC C4E based on provincial, district, and local contexts.
8. Respond to the needs of staff under constant pressure - The confidence of staff to carry out their communication work could be enhanced if they were: (i) supported - e.g., they need to be provided with tools and information to understand and respond to quickly to unfolding situations involving rumours or the rapid spread of misinformation; (ii) assured that their safety is paramount - e.g., the impact on families, communities, and staff of traumatic events such as the shootings, beatings, and harassment of polio workers - or just the pressure of regular community questions related to rumours - needs to be acknowledged; and (iii) motivated - e.g., training certificates, awards ceremonies, and staff acknowledgement events are important, but the context in Pakistan requires more.
9. Integrate social media with the overall communication strategy - Social media along with other media outreach needs to work towards creating an enabling environment, responding strategically to misinformation and rumours within the overall programme media strategy. The social media component also has the role of creating, posting, and providing material for others to use online, such as videos to back up community health workers (CHWs) at the doorstep, messages for social media influencers to share, information to counteract anti-vaxxers, and promotional material to support polio campaigns.

The report concludes with some reflections on what happened in April 2019. For instance, looking ahead, they recommend strengthening public support through wide promotion of:

• A report from the Government on what exactly happened in Peshawar and reassurance that this was not related to vaccine;
• Reassurance from the Government and credible medical influencers about the safety of vaccines overall, including OPV;
• Highly publicised statements from schools and parents that they are committed to vaccination; and
• Wide public support from public figures and influencers in the country (multi-party) that speak in support of vaccination.

Click here for the 29-slide report in PowerPoint format.