Evaluating Nongovernmental Organization-led Community Mobilizers in Health Promotion, Immunization Campaigns, and Acute Flaccid Paralysis Surveillance: A Systematic Review of the Evidence

"...CMs positively support social mobilization activities for the promotion of health messages, immunization campaign participation, and routine immunization; they have also remained a valuable tool for effective AFP case detection, reporting, and overall surveillance strategies in their respective communities for successful polio eradication program and routine immunization."

In the years following the Global Polio Eradication Initiative (GPEI)'s inauguration at the World Health Assembly (WHA) in 1988, the WHA urged polio-endemic states to engage local leadership and members of the community to foster acceptance of polio eradication interventions, including vaccination. Grounded in strategic communication, such engagement requires social mobilisation, partnership, and effective surveillance systems to guide polio programmatic action. This systematic literature review explores the effectiveness of non-governmental organisation (NGO)-led community mobilisers (CMs) to spread health messages, to promote immunisation campaign participation, and to improve acute flaccid paralysis (AFP) case detection.

For the review, a public health information specialist with experience in conducting systematic literature searches employed a combination of keywords that reflect CMs and polio eradication and routine immunisation. The study included studies published in the English language up to November 30 2020. A total of 1,627 articles were identified by the search, with 65 articles passing the title/abstract and full text reviews, and with 4 additional articles obtained from references of articles included (for a total of 69 articles). Of these 69 articles, 24 (5 reviews and 19 original articles) focused largely and explicitly on CMs and were included in the full review.

Some of the reviewed articles on the contributions of CMs to polio eradication were exclusive to certain countries, especially India, Nigeria, and Pakistan, whereas others were a part of multicountry investigation, as shown in Table 1 in the paper. Details of the studies' contexts and findings are provided in Tables 2-4. The literature points to the various mechanisms through which CMs participated, with an implication for ways to enhance their roles and integration into health systems (see Table 2). It also highlights their dynamic roles in various polio eradication and routine immunisation strategies in different settings (see Tables 3-6).

On the whole, studies found that promotion of health messages by CMs decreased resistance to polio vaccine uptake, such as in the high-risk districts of India and Chile, and increased community awareness about poliomyelitis. Other studies in the review describing the relationship between CMs and immunisation promotion for both immunisation campaigns and routine immunisation found similar results. Cutts found that urban immunisation programmes require intersectoral collaboration to mobilise community members and community structures to vaccinate eligible children and their mothers. This study also highlighted the benefits of community mobilisation to identify and refer eligible people for vaccination. Another study suggested that the selection of well-integrated CMs and proper training are vital components in improving vaccination rates.

Although CMs have consistently been shown to have beneficial effects on supporting routine immunisation services, studies of their roles in AFP case detection reported mixed findings. Lack of proper training and supervision were the most-cited reasons for the poor performance of AFP surveillance systems. One study indicated that the limitations of community volunteers and health extension workers (HEWs) in detecting cases of AFP were due to lack of knowledge of the formal case definition. Low literacy and lack of adequate supervision of the community volunteers led to less effective surveillance systems. The implication is that training CMs on case definition and the elements of community-based surveillance (CBS) will improve the ability of community volunteers and HEWs to detect and report cases of AFP.

Another barrier to establishing successful CBS systems identified in the reviewed studies is security. Research examined a broad range of strategies in the unstable states of Adamawa, Borno, and Yobe in Nigeria, where security challenges have led to the killing of health workers, destruction of health facilities, and displacement of large populations. Researchers identified the annual training of surveillance officers, an increase in the number of community informants, and media-based messaging (via radio and television) to sensitise the public to the importance of surveillance as the key strategies to strengthen case detection in these contexts. In fact, the literature suggests that efforts to improve AFP surveillance via mass media messaging should seek to reach entire communities, not only CMs. One study found that only about one-fifth of the studied sample in Nigeria were aware of AFP surveillance system/activities, and only 6.6% could give a correct definition of the meaning of AFP surveillance.

There has been some success with building effective community-based AFP surveillance. One study examined the introduction of CBS by the CORE Group Polio Project (CGPP) in Ethiopia. The system was created through a partnership between Ethiopian and United States (US)-based NGOs. The CGPP supported volunteers in capacity building regarding AFP and in facilitating case reporting. Volunteers additionally conducted active AFP searches, visiting community leaders who were likely to know of AFP cases. The researchers found a near doubling of AFP reporting in project areas since the implementation of CBS, according to key informant interviews.

Based on the findings of this review, it is recommended that CMs be provided with adequate supervision and support to improve their own and the communities' ability to contribute to routine immunisation and polio eradication initiatives and activities, notably through community participation and CBS. The CMs need sufficient and continual training on all aspects of their work. In addition: "the CMs' role should be expanded to work with other formally engaged actors in the GPEI, with increasing engagement in routine immunization and other aspects of health care as the GPEI enters its final stages. Identification and capacity building by hiring additional CMs should be cognizant of the limitations and experiences of the currently trained CMs. In addition, CMs and other actors in CBS need to be further motivated through capacity building and special recognition, especially in all high-risk communities."

In conclusion: "The literature on community mobilization for polio eradication indicates that CMs can be used to successfully improve vaccination rates, educate, and engage communities about polio and AFP. However, the literature is still fairly limited....Understandably, these studies are not easy to conduct as polio eradication campaigns are now mostly concerned with marginalized and isolated subpopulations. However, their findings can have an impact outside of polio eradication campaigns, indicating how to best engage with these communities to improve health outcomes."