Effectiveness of a Community-Level Social Mobilization Intervention in Achieving the Outcomes of Polio Vaccination Campaigns during the Post-Polio-Endemic Period: Evidence from CORE Group Polio Project in Uttar Pradesh, India

"The study provides evidence of an added value of deploying additional human resource dedicated to social mobilization to achieve desired vaccination outcomes in hard-to-reach or programmatically challenging areas."

India had the highest incidence of wild poliovirus (WPV) during the nineties, yet it became a non-polio-endemic country in February 2012 and was officially declared polio-free in March 2014. This accomplishment has been linked to contributors including the polio Social Mobilization Network (SM Net), which was established in Uttar Pradesh (UP), India, in 2003 to counter misconceptions about and community refusals of the oral polio vaccine (OPV). This paper assesses the effects of this community-level SM (CLSM) intervention on the extent of community engagement and performance of polio Supplementary Immunisation Activities (SIAs) during the post-polio-endemic period (i.e., from March 2012 to September 2017).

As detailed here, the UP SM Net implemented synchronised SM activities using community-level workers called Community Mobilization Coordinators (CMCs), who were supervised by Block Mobilization Coordinators (BMCs), who were in turn supervised by District Mobilization Coordinators (DMCs). The SM Net supported polio eradication in high-risk areas for polio, working with underserved communities to execute SM and other immunisation-related activities. The CMCs were deployed to advocate for vaccination in the selected polio high-risk areas (i.e., villages/urban wards) within administrative blocks of a district, designated as "CMC areas". Areas without CMC deployment were designated as "non-CMC areas". Hence, a block or polio-planning unit included both CMC and non-CMC areas. Since March 2014, the United Nations Children's Fund (UNICEF) has gradually withdrawn its CMCs, but the CORE Group Polio Project (CGPP) continued its CLSM efforts in 12 districts of UP.

Polio SIA operation in UP generally begins on a Sunday with fixed polio vaccination booths for one day. Then, the house-to-house vaccination phase begins. CMCs perform various awareness generation and trust-building activities before each SIA, such as: interpersonal (one-to-one and one-to-group) communication with caregivers and family members of children eligible for SIA vaccination; meetings with local influencers; and children's rallies. On booth day, the CMCs engage schoolchildren in encouraging the community to bring the children younger than five years to booths for vaccination. During the house-to-house vaccination, CMCs accompany vaccinators who vaccinate eligible children. If the vaccination team encounters refusal, CMCs engage the local influencers to convince resistant families to allow their children for polio vaccination. After an SIA, the SM Net functionaries visit all the houses with unvaccinated children and encourage family members to go for polio vaccination in the upcoming/next SIA. Sometimes, the block- and district-level functionaries of CGPP (i.e., BMCs and DMCs) even directly intervene in non-CMC areas to resolve the extreme situation of community-level resistance against polio vaccination.

This study followed a quasi-experimental design and used secondary, cluster-level data from CGPP India's Management Information System (MIS), including 52 SIAs held from January 2008 to September 2017, covering 56 blocks from 12 districts of UP. The researchers computed various indicators and performed analysis to assess the statistical significance of differences between the outcomes of intervention and non-intervention areas. They then estimated the effects of the SM intervention using Interrupted time-series, Difference-in-Differences, and Synthetic Control Methods. Finally, they estimated the population influenced by the intervention.

The performance of polio SIAs changed over time, with the intervention areas having better outcomes than non-intervention areas. The intervention areas had a significantly (p <0.01) higher level of community engagement (89.0%), by 18.2 percentage points, than non-intervention areas (70.8%). Both the areas had a very high level of mean SIA coverage (> 99%), but there was a statistically significant difference of 0.7 percentage points between the intervention and non-intervention areas. Mean booth coverage of CLSM intervention areas was significantly higher (p < 0.01) by 36.4 percentage points than that of non-CMC areas.

The data indicate that the absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the outcomes of polio SIAs. The percentage of children vaccinated at polio SIA booths, percentage of 'X' houses (i.e., households with unvaccinated children or households with out-of-home/out-of-village children or locked households) converted to 'P' (i.e., households with all vaccinated children or households without children eligible for vaccination), and percentage of resistant houses converted to polio acceptors would have gone down by 14.1 (range: 12.7 to 15.5), 6.3 (range: 5.2 to 7.3), and 7.4 percentage points, respectively. Community engagement would have reduced by 7.2 (range: 6.6 to 7.7) percentage points.

Dealing with resistance against polio vaccination was the unique salient point of the CLSM intervention. Reaching and converting about 424 (range: 322 to 527) resistant households to polio accepters in each SIA from CMC areas is described here as a substantial achievement, as the study areas in the past experienced many instances where the snowball effect of one refusal family led to more refusals, and there were instances where entire communities were against the polio vaccination drive. Eventually, the CLSM intervention increased engagement by 38,742 households, roughly translating into the inclusion of the same number of under-five children and a total population of 289,790 (Range: 267,500 to 312,088) in each of the polio SIAs of the post-polio-endemic period.

Thus, the study results show that the outcomes of polio SIAs in the CLSM intervention areas were equal to or exceeded the non-intervention areas' outcomes, even though the intervention areas were the more challenging areas for vaccination. The absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the performances of both the booth-based and house-to-house vaccination efforts of polio SIAs.

Based on the findings, the researchers suggest that a policy decision can be made to deploy additional social mobilisers or volunteers under the national health system or through other systems to address other public health challenges/issues, such as low routine immunisation (RI), harmful practices related to child care and feeding (including breastfeeding), and tuberculosis control. Large-scale public health programmes such as the National Health Mission (NHM) of India can apply the strategies and approaches of the SM Net initiative and build the communication skills and micro-planning capacities of Accredited Social Health Activists (ASHAs) to engage communities and perform their assigned tasks.

In conclusion: "Study findings indicate that the deployment of community-level paid volunteers, i.e., CMCs, was an effective strategy of SM Net initiative, even during the post-polio endemic period, to address access barriers and increase community engagement in polio SIAs. An intensified social mobilization or social and behavior change communication initiative with the deployment of dedicated community-level functionaries can be helpful to deal with the demand-side barriers in the utilization of public health services/schemes and achieve the desired outcomes of public health initiatives, especially in the areas with issues around acceptance of an intervention/program."