Determinants of Performance of Supplemental Immunization Activities for Polio Eradication in Uttar Pradesh, India: Social Mobilization Activities of the Social Mobilization Network (SM Net) and Core Group Polio Project (CGPP)

"Social mobilization activities can improve the performance of mass vaccination campaigns."

The primary strategy that has been employed to interrupt transmission of wild poliovirus in India is to improve supplemental immunisation activities (SIAs) and routine immunisation coverage in priority districts. The CORE Group, part of the Social Mobilization Network (SM Net), has been successful in improving SIA coverage in high-risk areas of Uttar Pradesh (UP). The SM Net works through community-level mobilisers (from the CORE Group and the United Nations Children's Fund, or UNICEF) and covers more than 2 million children under the age of five. This paper examines the reasons the CORE Group had been successful through exploration of which social mobilisation activities of the CORE Group predicted better performance of SIAs.

The high frequency of SIAs or mass campaigns in high-risk districts and blocks is designed to overcome "high immunity thresholds", meaning that an extremely high percent of the population needs to have immunity in order to interrupt transmission. During an SIA, oral polio vaccine (OPV) is given to all children in the group of 0–5 years as a part of the polio eradication programme. The yearly frequency of SIAs in India may vary from 4-12 and the scope can range from a district to an entire state up to the entire country. Grassroots social mobilisation efforts, including those of the CORE Group and SM Net, have been utilised to reach underserved populations during SIAs and combat rumours against polio vaccination in India.

The CORE Group is a United States (US)-based organisation made up of health professionals working for a variety of non-governmental organisations (NGOs) who collaborate on international health and development programmes. In India, the CORE Group Polio Project (CGPP), with funding from the US Agency for International Development (USAID), works in ten districts of the state of Uttar Pradesh (UP) through a consortium of private voluntary organisations (PVOs). The CGPP in India has an extensive network of 1,325 Community Mobilization Coordinators (CMCs) who conduct social mobilisation activities for behaviour change related to polio vaccination. These CMCs are a part of the Social Mobilization Network (SM Net) in India that includes CGPP, UNICEF, Rotary, and the Indian Government's and World Health Organization (WHO)'s National Polio Surveillance Project (NPSP). The SM Net was formed in Uttar Pradesh (UP) in 2003 to support polio eradication efforts there; a three-tier network of community mobilisers (community-level, block-level, and district-level) does the main work of the SM Net.

During SIA rounds, CMCs do the following: assist vaccinators in setting up vaccination booths; organise groups of child mobilisers (Bullawa tollies), who visit homes throughout the neighbourhood during booth activities; and help arrange for mosque and/or temple announcements, rallies, interpersonal communication (IPC) meetings, and meetings with influential people. CMCs also accompany vaccinator teams to homes with children under five years of age, work to convince families with an unvaccinated child (called an "X" household) to allow their child to be vaccinated (called converting an "X" household to "P"), and accompany persons of influence (influencers) during home visits. Conversion of "X" households to "P" is measured during each SIA round.

Weiss et al. (2011) found that vaccination outcomes were better in CMC areas than in non-CMC areas. To explore which social mobilisation activities predict better or worse performance in CMC areas as compared to non-CMC areas, the researchers carried out a secondary data analysis of routine monitoring information collected by the CORE Group and the Government of India for SIAs. These data included information about vaccination outcomes of SIAs in CORE Group areas and non-CORE Group areas within the districts where the CORE Group operates, along with information about the number of various social mobilisation activities carried out for each SIA. They employed Generalized Linear Latent and Mixed Model (GLLAMM) statistical analysis methods to identify which social mobilisation activities predicted SIA performance, and to account for the intra-class correlation (ICC) between multiple observations within the same geographic areas over time.

In brief, they found that the number of mosque announcements carried out was the most consistent determinant of improved SIA performance across various performance measures. The number of Bullawa Tollies carried out also appeared to be an important determinant of improved SIA performance. The number of times other social mobilisation activities were carried out did not appear to determine better SIA performance. In fact, there is evidence that a higher number of rallies is actually detrimental to the objective of increasing booth coverage. The researchers could not identify a clear reason for this finding about rallies and recommend placing more emphasis on fewer, high-quality rallies.

Reflecting on these findings, the researchers suggest that the CORE Group and SM Net should conduct sufficient numbers of mosque announcements (more than 48) and Bullawa Tollies (more than 43) in support of each SIA. The time period is usually within the month prior to an SIA. "It is likely, however, that the quality of social mobilization activities (not studied here) is as or more important than the quantity of activities; quality measures of social mobilization activities should be investigated in the future as to how they determine vaccination performance....Each block should carry out no more than 16 rallies and should consider focusing more on the quality than the quantity of the rallies, or consider shifting efforts away from rallies altogether....Documenting social mobilization activities that are not now being documented would allow evaluation of these other activities."