Eradicating Polio: Working with Religious Leaders to Enhance Community Ownership

"The role played by religious leaders [in polio eradication in India] is a positive example of how local community leaders can be engaged to produce proactive and sustainable local action."

This document provides an insight into how the United Nations Children's Fund (UNICEF) joined hands with religious leaders to give a new turn to the polio eradication programme in Uttar Pradesh (UP), India, an intervention that further created a strong platform to address other health and social challenges among minority communities.

As detailed here, India is a country of many religions. As per the 2001 census, about 78% of the UP population was Hindu, while Muslims formed around 22.2%. The latter is the second-largest community and the largest minority group in the state. The day-to-day behaviour of a majority of people in India is heavily governed by their religious affiliations, and the edicts issued by religious leaders greatly influence them and their lives. These religious leaders are held in high regard and have a mass following. Traditions and customs derived from religion also have a strong impact on the health related behaviour of communities.

During the polio eradication programme in India, many areas of UP were perceived as hotbeds for the polio virus. In a number of districts of the state with greater influence of polio, minority communities were resistant to the oral polio vaccine (OPV) and did not participate in the polio programme. Several myths and misconceptions related to the use of OPV were deeply rooted among these communities - e.g., that the polio drive was a government agenda to systematically reduce the minority population and that the vaccine had "questionable and religiously offensive" content in its formulation. There were instances when religious leaders advised the community to refrain from administering OPV to their children. This led to the polio eradication programme witnessing a devastating situation in 2002: That year, 1,242 of the total 1,600 cases reported in India were from UP. UNICEF positioned itself to face this roadblock by engaging with educational institutions and local and national religious leaders to join the fight against polio. (Editor's note: The World Health Organization (WHO) officially declared India polio-free on March 27 2014.)

Involving religious leaders in the polio programme thus became one of the main components of the Underserved Strategy (USS) - religious resistance being another challenge (in addition to dismal social, economic, and environmental factors) in the underserved areas, especially among the minority community. Religious leaders play a critical role, this document explains, because of the credence given to their words and the faith reposed in them. Their stature in the community provides them with a "social capital" that can be harnessed for eliminating myths and promoting appropriate behaviour. In particular, Muslim religious leaders have knowledge and understanding of Islam and hadith (a saying or an act or tacit approval or disapproval ascribed to the Islamic prophet Muhammad), and their messages are trusted and well accepted. As anchors of the community, religious leaders can bring people together and spread key messages/awareness simultaneously and effectively to a large audience.

UNICEF's overall strategy was to sensitise, engage, and sustain the commitment of religious leaders in the polio eradication programme. At the onset, a series of discussions were undertaken with Muslim religious leaders to understand their concerns. During this process, key religious leaders, who could be involved in the programme as supporters of the vaccination drive, were identified. Once this was done, they were sensitised by medical professionals, who clarified their doubts and myths about OPV. This was followed by a series of meetings and deliberations. Yet, a high degree of misapprehension about OPV persisted in their mindset. So, as detailed in the paper (see, e.g., figure 4 on page 15), UNICEF approached reputed educational institutions and personalities from various religious organisations - each of which was envisioned to have unique roles in the polio eradication programme (e.g., regular mosque announcements by Imams). At the national level, UNICEF approached Aligarh Muslim University, Jamia Milia Islamia (JMI), and Hamdard University. At the state level, UNICEF, along with JMI, approached Darul Uloom Deoband, a large seminary of Islamic learning. The Social Mobilization Network (SMNet) of UNICEF also approached and worked with district- and block-level religious institutions. As an example of an activity: Endorsements of polio vaccination by prominent religious leaders were made public through banners and pamphlets to reach out to everyone.

It was the SMNet that interacted with local religious leaders to reach the last member of the intended audience through door-to-door mobilisation. SMNet's Community Mobilization Coordinators (CMCs) identified and approached local religious leaders like Imams, Madarasa in-charges, Hajis, Maulvis, and others. They became local influencers in the polio eradication programme by addressing the community through announcements during Friday prayers, fairs, community gatherings, and religious meetings. Relevant materials in Urdu were developed and regular meetings with the religious leaders held to clarify doubts. The local religious leaders were also trained to answer queries about polio and OPV and counter prevalent myths and misconceptions. The one-to-one interactions with religious leaders were strengthened through the use of various audio-visual channels, such as:

• Street play / folk media to create awareness about polio through mosque miking (public announcement system) and Khudba
• Wall writings / hoardings / posters involving eminent/respectable personalities trusted by the community
• Eminent religious leaders providing positive messages through radio/television, especially for the illiterate population
• Advertisements and positive messages espoused by the religious leaders in the vernacular language in the local print media
• Customised information, education, and communication (IEC) materials that would appeal to the illiterate population

"Through these initiatives, an environment of trust was successfully created among the religious leaders. Though the process of bringing about a change in perceptions was a time-consuming one, it was ultimately sustainable. It led to a marked change in the attitude of the religious leaders and created a cadre of volunteers armed with knowledge and conviction about polio eradication."

Section 4 of the report shares specific results from this endeavour. Examples:

• From the inception of the programme in UP to the time of this publication, UNICEF engaged with 2,800 religious leaders and 2,000 madarasa teachers and principals as part of the strategy. Most of them underwent orientation training and later, actively participated in the programme. More than 500 madarasas participated during the UP campaign. In CMC areas, 5,788 Hajjis were engaged in the programme. Out of them, 1,974 Hajjis actively participated in community meetings, and 1,970 Hajjis inaugurated polio booths.
• Mosque announcements that increased over the years played an important role in the success of the programme. Figure 7 on page 23 shows the percentage of mosques that made announcements in the high-risk areas of UP over the period 2007-2012.
• Advocacy campaigns were organised during Eid-ul-Fitr (marking the end of Ramadan) as well. Mosque announcements and 'Taqreer' (formal speech/discussions on social and religious issues were held by the mosques authorities. Mosque announcements were made regarding date, day, and time of the polio vaccination and also to inform about the location of the Polio Booth. During Taqreer, discussions were held regarding the importance and benefits of vaccination. In the year 2012, out of approximately 2,900 Eidgaah/key mosques in the high-risk areas, almost 1,800 held taqreer during Eid-ul-Fitr. During Eid-ul-Fitr, IEC materials were also used. The Eid-ul-fitr advocacy campaign in UP in 2012 gave key messages on the polio eradication programme to more than 9 million people.

UNICEF asserts that the successes of this intervention in the polio programme in UP can and should be replicated in other health interventions. To facilitate this, the report points out lessons learned from the challenges. For instance:

• Be proactive: Involve and approach religious leaders at the beginning of any intervention. Once a myth or misconception is ingrained, it becomes more challenging to counter it.
• Get to know your partners in change: Before you approach religious leaders, it is important to understand their background and knowledge level and approach them accordingly. A positive impact in the initial meeting could help to create the platform for a long-term partnership.
• Adopt different strategies for different religious groups: As far as possible, every community and leader should be dealt with in a unique manner, addressing their respective concerns.

"Considerable efforts are being made to deepen partnerships with the minority communities whether it is for identifying common ground and encouraging open dialogue or about complex and sensitive issues."